Internet technologies hold the promise of engaging young people with mental health problems through routes which are familiar to them, as well as supporting leaner, greener, digital public services, with greater involvement of informed consumers and reduced use of ‘real-world’ resources. Such technologies are becoming ubiquitous as costs fall and e-literacy rises and ever more devices become networked.
A generation of ‘digital natives’
Young people aged 16-24 years have been characterised as ‘digital natives’, Reference Prensky1 a term used to describe those who have grown up with the internet, mobile telephones and other technologies, and who are fundamentally different from previous generations in the way they communicate, seek information, engage, interact and entertain themselves. Increasingly, young people access the internet through mobile telephones and games consoles. 2 They have expectations that public services such as healthcare will be digital. The advent of Web 2.0 technology is transforming social relationships, which are now played out in online settings, whether public or private − 77% of those aged 16-24 years have at least one social network profile. 2 The default mode of communication for young people is becoming text-based. In a population of university students, Horgan & Sweeney Reference Horgan and Sweeney3 found that many (31%) had searched for mental health information online in the past and 68% reported that they would use the internet for mental health support, although there was still a preference for face-to-face support. The importance of internet technologies to young people was demonstrated in a survey of 16- to 24-year-olds conducted by Hulme for the UK charity YouthNet. Reference Hulme4 In the survey, 75% reported that they could not live without the internet; 45% felt happiest when online; 37% would use the internet to give advice to others on sensitive issues; and 32% agreed with the statement: ‘I can access all the information I need online, there is no need to speak to a real person about my problems’.
Opportunities and challenges of the internet in mental health
At the same time, there are unanswered questions as to the health and social impact of this technological revolution and its effects on mental health. Concerns range from issues such as cyber bullying, Reference Agatston, Kowalski and Limber5 child pornography and sexual predation Reference Dombrowski, Gischlar and Durst6 and internet addiction, Reference Ha, Kim, Bae, Bae, Kim and Sim7 to the content of pro-anorexia or pro-bulimia websites, Reference Tierney8 and reports of online suicide pacts and pro-suicide websites. Reference Biddle, Donovan, Hawton, Kapur and Gunnell9 Since the early days of the internet, practitioners and academics have expressed anxiety about the proliferation of ill-controlled, non-moderated, user-generated content and debated whether this will misinform patients and the public and lead to inadvertent harmful health behaviour. Reference Bell10 Yet, despite sporadic case reports, there is still no systematic evidence of inaccurate online information (of which there is a great deal) leading to widespread harm. For the most part it seems that people are aware of the risks and benefits of online advice and make their own calculated judgements which take into account the provenance of information. Reference Powell, Inglis, Ronnie and Large11
Online communities for self-harm
The paper by Jones and colleagues Reference Jones, Sharkey, Ford, Emmens, Hewis and Smithson12 in this issue of The Psychiatrist is a welcome contribution to the emergent literature on the role of self-harm communities on the internet, and to the virtual community literature more generally. In their study they created three communities to which they recruited young people with histories of self-harm, together with volunteer health professionals. Through using a questionnaire survey supported by an exploration of the postings of users, Jones et al identify some of the motivations and benefits of an online self-harm community. They found that participants placed particular value on being able to communicate with strangers, anonymously, about their self-harm issues; this was easier than speaking to someone in person or on the telephone. They agreed that they learnt more from community sites than informational ones. They valued the benefit of interacting with others ‘who had the same feelings’. The issue of trust appeared to matter less than might have been expected given the concerns expressed by professionals.
The above supports some of what we already know about health internet use and virtual community use - that anonymity, privacy and convenience are valued, as is the opportunity to share experiences with others. Reference Powell and Clarke13 Accuracy of information appears to be more of a concern to commentators than actual users. Reference Powell, Inglis, Ronnie and Large11 Other studies which also examine self-harm communities concur with the potential benefits of social support to reduce isolation and loneliness Reference Whitlock, Powers and Eckenrode14,Reference Rodham, Gavin and Miles15 and the provision of a forum for venting feelings. Reference Rodham, Gavin and Miles15 These other studies have questioned whether such communities can cause harm by legitimising and normalising negative behaviours and contributing to their maintenance, as well as possibly introducing new harmful behaviours. Reference Whitlock, Powers and Eckenrode14,Reference Rodham, Gavin and Miles15 Most recently, similar ‘normalising’ concerns have been expressed in relation to self-harm videos posted on the video-sharing website YouTube. Reference Lewis, Heath, St Denis and Noble16 It is significant, as the authors themselves highlight, that the study by Jones and colleagues used moderated settings, where some of the potential negative effects, such as may occur through normalisation or introducing new harmful behaviours, could be addressed.
Practitioners need to catch up with technology
Jones and colleagues follow others Reference Bell10,Reference Baker and Fortune17 in rightly calling for a better understanding by mental health professionals of the use of online settings by those who self-harm, and there is a general need for practitioners to understand mental health-related internet use. There is no doubt that the unregulated, distributed, democratising nature of the internet provides a fertile ground for subcultural discussions. There is also no doubt that the pervasive nature of networked technologies and their convenience, their ‘always on’ accessibility, and their relative anonymity, mean that their use by the ‘net generation’ of young people will only increase. By understanding the nature of online exchanges in self-harm forums, whether moderated or not, practitioners may begin to identify the balance of potential benefits and harms, Reference Mitchell and Ybarra18 and explore how the benefits may be harnessed. Future research that builds on the work of Jones and colleagues should investigate the relationship between self-harm community use and actual behaviour, including the effects on health and social outcomes. The limited existing work in this area suggests that such communities might be able to reduce the frequency and severity of self-harming behaviour. Reference Murray and Fox19 Such research, combined with the insights of practitioners becoming familiar with online mental health settings, could in turn inform the development of targeted internet community interventions that have high accessibility and acceptability to young people.
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