Dr Holan Liang treats children with severe mental health issues. Born in Taiwan, she moved to the UK as a child and studied medicine and experimental psychology at Cambridge, before training in psychiatry at The Maudsley Hospital.
n her latest book, A Sense Of Belonging: How To Find Your Place In A Fractured World, Dr Liang explores the topic of loneliness and the pull to ‘fit in’ at different stages of our lives.
Here, Dr Liang, as the daughter of Chinese immigrants, discusses the taboo topic of loneliness and how the social media platform TikTok has resulted in teenagers developing tics during lockdown.
“Loneliness is not the same as solitude or choosing to spend time in our own company. It is about a disconnect between our desired quantity and quality of social interaction and what we actually achieve. It can occur at any age and can happen to any of us.
“The negative impact of loneliness on people is hard to overstate; it is known to be associated with physical and mental illnesses, including blood pressure issues, poor sleep, dementia, depression, suicidal ideation and even premature death.
“A 2010 study of the impact of loneliness on death rates estimated its effect to be double that of obesity and quadruple that of air pollution, making it a key emerging public health concern. It is estimated that in the West, a third of people are affected by loneliness, with one in 12 severely affected.
“Scientists have also been studying how the experience of loneliness can affect our psychology and have found that it causes changes in measurable brain structure (differences in grey and white matter). Given that the brain is the primary organ for making sense of our environment and controlling our bodily responses, this should perhaps come as no surprise. It just goes to show the powerful effect of the environment and, crucially, our interpretation of the environment, on our mental and physical wellbeing.
“Social isolation, however, is not the sole cause of loneliness and many can feel lonely even when surrounded by others. Scientists used to measure loneliness by monitoring the extent of people’s social contact and group membership, but they now know that quantity matters less than quality. It is more about how well you identify with a group than the number of groups you belong to, or the number of social interactions.
“You may, for example, be a member of the school football/basketball team, while your real passion is for singing and dancing (think of the characters in Glee or High School Musical).
“You may be part of a heterosexual couple and a loving family unit but be gay (a recent example being the TV presenter Phillip Schofield). Perhaps you feel like you know lots of people but are not really known by anyone. Recognising that you are not being your true or full self with those around you can lead to a lonely existence, fuelling mental health problems.
“Second only to the elderly, teens are well known to suffer loneliness and isolation. Adolescence is a time when identity creation is to the fore, when experimenting with self-expression through peer connection and competing for social hierarchy are important rites of passage. The downside of competition for social hierarchy is, of course, that bullying, and more recently cyberbullying, is highly prevalent and a well-known contributor to loneliness.
“A literature review on social isolation and loneliness in teenagers during lockdown showed increased risks of depression and anxiety among this group, prompting fears that there will be a massive increase in demand for already stretched child mental health services in the aftermath of Covid-19.
“Indeed, my own Tourette’s service has already seen a doubling in referral rates for teenage girls, many of whom are presenting with unusual tics (the making of involuntary movements and sounds), which can be both florid and exaggerated.
“These tics are not like the movements associated with Tourette’s syndrome and are more likely to be functional tic-like actions, often generated by psychological triggers such as anxiety. This is partly a consequence of the social isolation and educational uncertainty that arose from school closures due to Covid-19. An added notable observation was that some had the exact same tics displayed by Tourette’s influencers on social media platforms.
“There is concern that social media sites such as TikTok may have had a part to play in this phenomenon. These sites have exploded in popularity and videos of influencers with tic-like symptoms have gone viral. For example, the hashtag #tourettes on TikTok has 2.5 billion views, with numbers doubling in the month of January 2021 alone.
“Although teens report that they gain peer support and recognition from this exposure, this ‘support’ may also be inadvertently reinforcing and maintaining symptoms, as well as opening the door to the potential for ‘contagion’ among vulnerable individuals.
“Parents and commentators are understandably concerned about the potential impact of social media on children’s mental health, questioning whether this form of interaction could damage their real-life social ability, by reducing the amount of face-to-face contact they have with others and stunting their communication and empathy skills, thereby fuelling social isolation and loneliness.
“These are important issues to consider, with depression and anxiety levels in children having risen over the past decade — ie, even prior to Covid. But, as ever, the picture is more complicated than it looks at first glance.
“A growing body of evidence suggests that social media use is not detrimental to children in and of itself — indeed, the use of social media has been linked to mental health benefits as well as problems. Rather, social media is a mood reflector or enhancer, and while happy children with good self-esteem may gain support and positivity from it, those with low self-esteem and low mood may use it in a way that is detrimental to their mental health.
“Evidence to support this includes Chloe Berryman’s 2018 study on this topic, which found that adolescents who lack confidence and are prone to making comparisons between themselves and peers on social media are more susceptible to depression; whereas teens who are able to present themselves authentically are more likely to have wellbeing benefits from social media use.
“Her study found no direct associations between hours online and loneliness, but revealed that good parent-child relationships and social support were protective factors.
“Certainly, children who feel rejected by the world can be drawn into online communities which seem to offer them a sense of belonging — and which may or may not have their best interests at heart. Some websites can raise awareness of mental health problems, while others promote unhelpful depictions for entertainment purposes; equally, some support groups empower members to live fully and recover, while for others membership and ‘belonging’ is dependent on them maintaining their illness. My take-home message from this research was that we need to have more awareness at a granular level about the ways in which vulnerable teenagers are using social media.
“If meaningful relationships are the essence of life, then the more we have, the fuller our lives and the hardier and more resilient we become to life’s adversities. Evidence backs this up, as studies show that having a wide network of social ties and good personal support helps people withstand higher levels of stress.
“But even if we have generally been quite successful at maintaining good, supportive friendships, things can change, and at some point in our lives, perhaps through a house or job move, we may find ourselves needing to establish new relationships. One way in which we can make this potentially daunting prospect much easier is by changing our mindset so that, instead of being afraid of rejection, we start to view everyone as a possible friend.
“When we look back at our lives, making friends in nursery and reception seemed so much easier than at any other subsequent time. This is often because very young children have not yet developed the hang-ups, insecurity and negativity that life inevitably generates in us. We saw everyone in our nursery class as a possible playmate; we behaved naturally with the assumption that other people would like us. For most people, making friends in nursery was a matter of playing together and smiling.
“If we see everyone as a potential friend, rather than worrying that they, or we, are the ‘wrong’ race/intellectual level/social class etc, then making friends becomes a lot easier. Look for things that others have in common with you, rather than focusing on differences, and you’ll soon realise that there are many more people that you can relate to than you thought. The less we judge or make assumptions about others, the less likely we are to feel judged.
“By being open-minded, we can often be surprised to find that people who appear superficially different are more like-minded than we imagined. Without this attitude, I would never have got to know my husband, Andrew, for, as someone politically incorrectly put it to me, we were superficially different: ‘How come you two are a couple? You have s***** eyes and he has round eyes.’ I should have replied, ‘Because the shape of our eyes is irrelevant; we have the same hearts and minds,’ but unfortunately the best comebacks are always the ones you think of days after the moment has passed.
“When I had problems at work, it was largely the compassion of my colleagues that helped me through, as they were the most likely to understand the particular nuances of my experience. I also discovered a wonderful social media group called Physician Mums Group UK, formed of some 20,000 doctors who were also mothers.
The support I obtained from this virtual bunch of strangers was literally lifesaving (the access to instant medical advice was an added bonus). So you can see that, despite the bad press of social media, it also has myriad benefits.
If you have a problem, it’s very likely that someone out there on the internet has been through something similar and is willing to offer support.
A Sense Of Belonging: How To Find Your Place In A Fractured World by Dr Holan Liang (Short Books, £12.99) is out now.
