In Conversation… Dr Farhana Mann on Loneliness

Dr Farhana Mann gives a general overview of the landscape of loneliness and its impacts on children and young people.

As an inherently social species, the two discuss how a lack positive social relationships can be potentially harmful, the impacts it has on psychical and mental health, research showing a higher rate of loneliness in areas of deprivation and the need for research to be conducted in younger populations.

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Farhana is an award-winning psychiatrist and academic at University College London (UCL). Her area of research interest is social relationships, loneliness and its effects on people with or without existing mental health problems. She has won a number of awards and contributes to the media as an expert. She is always keen to promote better public understanding of psychiatry and mental disorder. Follow Farhana on Twitter @FarhanaMann

Transcript

Introduction: This podcast is brought to you by the Association for Child and Adolescent mental health ACAMH for short. You can find more podcasts and other resources on our website www.acamh.org and follow us on social media by searching ACAMH.

Interviewer: Hello, welcome to the ‘In Conversation’ podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlow a freelance journalist with a specialism in Psychology. Today, I’m interviewing, Dr. Farhana Mann, A psychiatrist and welcome clinical research fellow at the division of Psychiatry at University College, London. Farhana is going to give a general overview of the landscape of loneliness and its impact on children and young people. Farhana, welcome. Thank you for joining me. Can you start with an introduction about who you are and what you do?

Dr. Farhana Mann: Thank you very much for having me on yeah, I am as you mentioned a psychiatrist. So I’m a doctor in London and I’m also a researcher at UCL.

Interviewer: And you are particularly interested in social relationships, loneliness and their association with mental health. What prompted this interest?

Dr. Farhana Mann: In fact, I started off my research journey in the laboratory. So quite removed from the field I now find myself in. The first degree was in immunology and cell pathology. But then after medical school during the time I was training as a psychiatrist, I would of course spend lots of time figuring out, as a team how to help people in the real world with mental health problems, and as a psychiatrist, we try to do that in a number of ways. But at the core of it all is the hope of forming a sincere connection with another human being in order to work towards recovery.

And the other thing that I noticed was that whenever I was on call in the middle of the night or in an emergency situation, I would tend to worry less about the people I knew had a network of supportive relationship outside of the clinical contexts. And the people that I knew had someone to turn to if things were to deteriorate. And it became increasingly clear to me that for most people there was something protective and helpful about positive social relationships and potentially harmful about a lack of them. And that we’re inherently a social species.

Interviewer: Let’s talk about loneliness. It’s not the same as solitude and sometimes people talk of feeling lonely, even when they are amongst other people. So I think it would be really helpful to start with the definition of loneliness.

Dr. Farhana Mann: I mean, it’s important because there are a number of related concepts when it comes to the broader field of social relationships and we’ve written a bit about that and it is important then to try to define exactly what we mean when we talk about loneliness. A definition that I like, and there are there are a few broadly, what they mean is it’s a perceived mismatch between the quality or quantity of social connection that a person has and what they would like. So crucially we’re talking about a pervasive unpleasant experience.

In our research the experience of loneliness that we talked about is normally one that a person finds undesirable and the other thing to mention is that there is of course, there is of course overlap between different concepts. So for example, the idea being physically isolated isn’t isn’t the same thing as feeling lonely. But if you are isolated, you’re more likely to feel lonely statistically. So they will cross over and in that way.

Interviewer: What does the research show in terms of the impact of loneliness on both physical and mental health?

Dr. Farhana Mann: So there is now a good amount of scientific evidence to show that loneliness is associated with both physical and mental health problems. One very highly cited paper highlighted how loneliness specifically was associated with a risk of dying earlier in adults from from all causes, after adjusting for various other relevant factors. Thinking about physical health first, in terms of physical health, loneliness is associated with lots of poorer kind of physical health outcomes, including cardiovascular health, so things like blood pressure or strokes, altered immune function and poor sleep and poor outcomes in lots of other chronic health problems.

But was a bit surprising when we first started looking into loneliness and its effects on Mental Health, was that there was relatively less good quality research on it out there compared with physical health. We do know that loneliness is strongly associated with problems like depression and anxiety and from our own reviews, we know that people with existing mental health problems tend to do worse if they’re lonely compared with people with mental health problems who aren’t experiencing loneliness.

And there’s also growing evidence that loneliness is a major concern for many people with severe mental health problems, like schizophrenia or other psychotic health issues or bipolar disorder as examples. As well as other issues like personality disorder. So lots of people with a range of different kinds of mental health issues will experience loneliness. And it is looking at it whether loneliness and of leads to the onset of mental health problems. Also, what impact being lonely has on people who have mental health problems. So those are all things the better understand.

Interviewer: What does the research say on that last point?

Dr. Farhana Mann: Well for most of the research that’s out there at the moment, and there’s lots still going on is on depression and certainly in that it seems to be that there’s a reciprocal relationship. So that if you’re lonely and you don’t have depression, you do seem to be at increased risk of getting depression. Again most that he’s from some studies of older people. But also that if you have depression, you’re more likely to experience to become lonely every time so it does seem to be both ways.

Interviewer: Now when we talk about loneliness usually people think about elderly people, so nearly all public health discussions around loneliness do focus on older people. Why is that do you think?

Dr. Farhana Mann: No, I agree. So that’s certainly what we’ve found when we’ve conducted reviews of the evidence that the vast majority of published research is in older people and that’s changing. There is more being done in younger people. Most of it is in People aged 65 or more.

I think that potentially a number of reasons for that, including the fact that we tend to see old age as a more perhaps obvious time for people to experience loneliness as they may have gone through bereavement, younger family moved away, less likely to be in the workplace or get around due to physical disability etc. and the science backs it up to an extent, in that when you study cross-sections of the population and look for who is experiencing loneliness and it being a problem there is a peak in older people. But crucially when you do that, you see that there is also a peak in young adults kind of 16 to 25 and I think recently in the UK that there was even more of a problem in young people. So we have seen a shift to try to better understand what’s happening across the age range and especially in young people.

Interviewer: And how prevalent is loneliness amongst children and young people?

Dr. Farhana Mann: It’s a good question again following on from what you mentioned before, we have less data across the relations to draw on compared with in older people. But, and especially we know we the least about very young children, kind of under tens. And what we tend to know it tends to come from Western countries, but some of the estimates and from the data that we have is, so one Finnish study looked at cohorts of eight-year-olds over many years, four years and they found about 20 percent of the kids reported loneliness is an issue. But about five percent said it was more of a persistent problem and the things that you could draw from that research due to the children who reported more loneliness were more likely to come from those kind of non-nuclear family, have parent the lower level of vocational education and also have experience negative life events. And over time, there was a strong link with having psychiatric problems and having been lonely.

In a recent ONS survey, so that’s UK and children a little bit older. So 10 to 15 about 11 percent of overall said that they often felt lonely. Again things you could pick out whether it was higher in children on free school meals though. If you live in the city versus a rural area and also if your general health was worse and interestingly if you specifically have difficult family relationships. And then in the older group, so 16 to 24 I know they are not necessarily children, but young adults about 10% said they often felt lonely. Again, it was much higher in certain circumstances. So, if you had any kind of disability or long-term illness. And also if you lived in a single adult household, it was higher and higher than that, but on average about 10%.

Interviewer: It is pretty high actually and you also seem to be implying there’s some kind of link between deprivation and loneliness?

Dr. Farhana Mann: Yes, so we know that is the case in sort of mental health problems in general. It’s not that it doesn’t mean that you only get mental health problems if you experience deprivation, not at all, but there is that association so it’s very relevant. And we are finding that that is the case with loneliness not just in young people but in older people and other adults as well.

Interviewer: I want to look at the impact of loneliness on young people, what were your findings?

Dr. Farhana Mann: Young people typically go through a number of important transitions including for example, moving from primary to secondary school. Perhaps going into university or entering the job market, so lots of kind of shift and change. In terms of impact, so probably some important findings from a study of young people by Tim Matthews and colleagues was that lonelier young adults more likely to experience mental health problems, but also to engage in physical health risk behaviors and also to use more negative strategies in order to cope with stress. They were less confident in employment prospects.

So, their own perception of their own employment prospects and were more likely to be out of work alone young adults as children. Also more likely to have had mental health difficulties and to experience life events, like bullying or being physically isolated. So all those things are looking like they’re they are related.

Interviewer: How might parents or professionals pick up on the fact that a child or teenager is lonely. Is it something that’s kept hidden or are there particular red flags?

Dr. Farhana Mann: It’s important to note that could it could vary hugely depending on the child, their circumstance, their age etc. and you may notice that they aren’t perhaps engaging in social activities with friends. If there’s been a change in behavior and they become withdrawn or in some people it may be associated with a person feeling more anxious for example, so how it’s manifesting might be different. And again as you suggested it might not be obvious to a parent at all in some situations. But all of the issues that I mentioned earlier on to things like bullying, low mood, poor self-esteem, feeling stressed etc.

All of those things may be relevant, so those might be the things that you pick up on. I think the key thing is not to be afraid to ask about it. But also to think about doing it in this sensitive and supportive a manner as you can because what we do know is that young people have talked about it as being something that’s very embarrassing to talk about. So don’t let that stop you asking but just be aware that it’s something that might not be easy.

Interviewer: So how might a parent ask because I imagine if you say to a teenager are you lonely, don’t you have any friends? That wouldn’t land very well.

Dr. Farhana Mann: Again, it depends obviously on what the relationship is like between those two people and their level of communication they normally use, but I think keeping things open, starting off with a more open question about how things are, how they’re getting on in general and then you know, it may invite someone to bring up a certain issues around friendships etc. if you’re not feeling like going straight in into the question.

Interviewer: And if you do pick up on the fact that your child is lonely, where’s the first port of call for help?

Dr. Farhana Mann: Well, the first thing to note is that it may be very helpful in itself that you’ve opened up that conversation in the first place again. I know I keep saying this but one size won’t fit all, depends on the child’s age. And also how that loneliness is affecting them. If it’s something you know, and what may be driving it. It may be that in somebody it’s a sort of sense of lacking confidence in social skills, for example, so the approach may be something quite practical.

It may be well we could practice what we might say in a conversation, you know with the younger child or rehearse what you might do if it’s that sort of issue. On the other hand if it’s something more complex and you think actually it’s a child who maybe has felt lonely for some time and actually you’re worried about their mental health or they’re feeling depressed etc.

Then you could think about perhaps starting talking with the GP, going along together or offering for the child to have a chance to talk with the doctor themselves. There are also other organizations, charities, places like that where you could you could reach out depending on how the problem was kind of manifesting, but certainly, if you’re worried about mental health then an obvious point of contact could be picking up the phone and maybe having a chance to talk with the GP or someone else at the surgery that might be able to sound things out.

Interviewer: And what interventions are available to help children and young people deal with loneliness and social relationships? And what does the research show to be effective?

Dr. Farhana Mann: So this is area of ongoing research again, most of research into what works to reduce feelings of loneliness is specifically looking at if the loneliness reduces is in older people. So I wouldn’t feel confident saying we know exactly what type of intervention will work to stop young people feeling lonely because we’re still trying to answer that question, well. We can draw some conclusions from what we learnt from older people.

But of course experience of loneliness at age 80 may be very different to what someone is going through when they’re 15, for example. So we can’t extrapolate too much. But something to keep in mind is that there are different levels that we can approach the issue of an individual’s loneliness. You can work with individuals at the individual level or they can be interventions more at a community level other things like opportunities for volunteering, social prescribing things like that. And then much wider interventions that may be direct or indirect tackling things like poverty for example. And all of those things need to happen at those different levels. So it isn’t just about working with a person who is lonely but also thinking about the context in which that person exists.

But thinking specifically about the individual level but there is some evidence that helping people shift their ways of thinking about the loneliness could help reduce it through approaches, like cognitive behavioral therapy, for example. Or other individual therapies that may look at things like a person’s social identity. But it is early days in terms of specifically in young people demonstrating what is most effective for whom.

Interviewer: And should the whole family being involved. Is it important to involve parents and carers in any interventions?

Dr. Farhana Mann: In general I’m a strong believer in involving family in a positive way whenever possible. But of course that could be easier in some situations and maybe more appropriate in some situations than other, for examples in younger children that may be easier, not necessarily but it might be.

And there’s always a need to balance inclusion with being intrusive into a young person’s space. But there are ways around that you can offer a space for young person and another space where they could also talk the family. And they’re certainly the evidence, I mentioned earlier that young people who have more difficult family relationships in particular are more likely to struggle with loneliness. I definitely think it’s a very important consideration in mental health in general, but particularly with loneliness.

Interviewer: What about digital technology? Is that being used to help young people feel better connected?

Dr. Farhana Mann: Yeah. This is an area of research that I definitely would like to see grow. We tend to hear more in the media about through harmful effects of quite rightly and in many situations like social media how it can crash self-esteem or provide a platform for bullying and those are very important considerations. So that should continue to be something we think about but there’s also a need to better understand how technology can be part of the solution, because I’m confident that in those situations, it already is and can be.

So young people spend a lot more time, of course using technology to connect than people my age or older and I honestly believe there is huge potential to try and do good. My own contribution partly is that I am co-founder of a social impact company myself KETKA, where we use storytelling to help children from a very young age explore ideas around making friendships, around social skills, around other aspects of things like self esteem, bullying etc. Through adventure stories and connect parents into the picture to so trying to bring families into it.

So I think there’s lots of innovative and creative ways we can bring families together and explore mental wellbeing in a fun way that’s accessible and can be scaled. But we’re also trying to build in sort of research to try and demonstrate how it works and who it works for, so it’s an area that’s growing but I definitely think there’s lots of potential.

Interviewer: Do you have a link be kept for him in case anybody wants to look that up?

Dr. Farhana Mann: Yes. Absolutely. So it’s ketka.co.uk

Interviewer: We are speaking in 2020. During the coronavirus pandemic and we’re currently in lockdown. This situation may change over the coming months, but I’m wondering what you feel the impact is in relation to young people and loneliness given that currently children and teenagers cannot meet up and socialize with their friends in the normal way. Any thoughts on this?

Dr. Farhana Mann: Yes absolutely they won’t necessarily be evidence-based thoughts at this stage, but that will change as there are number of institutions globally and including UCL conducting rapid research into the effect of this kind of isolation or loneliness on mental health. What we know is that it’s likely to affect different people in different ways. It’s certainly possible that young people who don’t have access to technology for example could become quite cut off from their networks and an experienced loneliness.

But at the same time young people are better at using tech in general to connect another people so it may be that many will adapt very well. I was speaking to a parent the other day who said her daughter who’s 11 was old enough to live her life on social media, but not old enough to be going out and socializing with friends. So lockdown actually suited her very well. So it will affect different age groups in different ways.

It’ll be important, I think in particular to see what happens to young people who already have existing mental health problems and then experience the lockdown on top of it. And of course aside from the loneliness and related issues like uncertainty about education, worrying about their families health or their own health, employment etc. will all be relevant to their overall mental wellbeing.

Interviewer: I believe you’ve commented in the past that researchers need to be more proactive and involving young people in the research process. Is this starting to happen? And if not what can be done to make research in this area more relevant?

Dr. Farhana Mann: I think certainly in mental health. We are getting better at including a wider range of voices in the research process. So from the very early stages of even planning their research questions, through to disseminating findings. It’s now an essential requirement for most grant applications. And that’s a good thing. But the key now is to make sure that we continue to do that but also ensure that the involvement of service users or young people in the general population is done in as a meaningful manner. And also that those young people are as representative as they can be for people who were trying to sort of learn about or learn with.

Interviewer: How does one go about involving young people in the research process?

Dr. Farhana Mann: There are lots of ways of doing that and I’m sure there are people listening who will suggest even more. It depends on whom you’re trying to reach. For example, if it’s people with existing mental health problems, whether it’s carers or people in the general population who don’t have existing mental health problems. Working with third sector organizations we found can be extremely helpful.

Dr. Farhana Mann: So having partnerships in that way as well as some universities or schools. And of course using social media. The thing I think is most challenging is reaching some of the more vulnerable groups of young people who may not typically get their voices heard and that does require a bit more effort.

Interviewer: Thank you. What more would you like to see in terms of research? Are there any current projects that excites you?

Dr. Farhana Mann: Yeah, there’s lots going on. I would like to see more good quality research into the effects of social media and how young people are engaging with it. It all changes so rapidly that it can be hard for researchers to keep up. And it’s same time there’s this wealth of potentially life-saving information and data to be learned from so it’s about doing it responsibly and rapidly, so that it can translate into something useful like a real-world intervention.

Interviewer: And is there any think you believe should be done at a local or national level in terms of policy, resources and training and so on to improve the situation?

Dr. Farhana Mann: If I had to pick one thing and what keeps coming up is that poorer mental health in general, physical health for that matter is associated with poverty and deprivation. And that’s also the case for loneliness. Now while that’s not everything, I do think that wider measures that give children and their families and young people a stronger sense of security in that sense will help.

Interviewer: Farhana, finally. What is your takeaway message for those listening to our conversation?

Dr. Farhana Mann: Well, I would say don’t ever underestimate the power of connecting with another human being, whether in person or remotely. If you’re struggling one of the most powerful things you can do is share what you’re going through with someone you trust. If you’re not lucky enough to have those connections at home or have close friends and don’t hesitate to pick up the phone and attempt to speak with a person from the support organization or reach out to them through social media because it’s a very good place to start.

Interviewer: Brilliant. Thank you ever so much for more details on Dr. Farhana Mann, please visit the ACAMH website www.acamh.org and Twitter @ACAMH. ACAMH is spelled ACAMH.