Young people, self-harm and internet forums Commentary on . . . Online discussion forums for young people who self-harm

A generation of digital natives are living their lives in fundamentally different ways from previous generations. The rapid advance of the internet and mobile telephones, and the adoption of online social media, mean that substantial parts of the social lives of young people are played out in online settings. This has implications for how young people discuss and seek help for mental health problems. This commentary discusses the role of online forums for young people who self-harm. Practitioners need to understand the potential harms and benefits, and explore how benefits can be harnessed and harms minimised.

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', 1 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][17][18][19][20][21][22][23][24] years have at least one social network profile. 2 The default mode of communication for young people is becoming textbased. In a population of university students, Horgan & Sweeney 3 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. 4 In the survey, 75% reported that they could not live without the Summary A generation of digital natives are living their lives in fundamentally different ways from previous generations. The rapid advance of the internet and mobile telephones, and the adoption of online social media, mean that substantial parts of the social lives of young people are played out in online settings. This has implications for how young people discuss and seek help for mental health problems. This commentary discusses the role of online forums for young people who self-harm. Practitioners need to understand the potential harms and benefits, and explore how benefits can be harnessed and harms minimised. 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, 5 child pornography and sexual predation 6 and internet addiction, 7 to the content of pro-anorexia or pro-bulimia websites, 8 and reports of online suicide pacts and pro-suicide websites. 9 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. 10 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. 11 Online communities for self-harm The paper by Jones and colleagues 12 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 selfharm, 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 usethat anonymity, privacy and convenience are valued, as is the opportunity to share experiences with others. 13 Accuracy of information appears to be more of a concern to commentators than actual users. 11 Other studies which also examine self-harm communities concur with the potential benefits of social support to reduce isolation and loneliness 14,15 and the provision of a forum for venting feelings. 15 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. 14,15 Most recently, similar 'normalising' concerns have been expressed in relation to self-harm videos posted on the video-sharing website YouTube. 16 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 10,17 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 healthrelated 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, 18 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. 19 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.
An editorial in The Psychiatrist was entitled 'Everybody gets stressed . . . it's just the way we react that differs'. 1 This suggests that the stigma of mental illness may be reduced by encouraging people to think that mental illness is an unusual reaction to stress in otherwise 'normal' people (the 'stress' model of mental illness). This, presumably, contrasts with a biological or 'illness' model which suggests that individuals who have a mental illness have a distinct abnormality of anatomy, physiology or biochemistry that makes them different to normal people and renders them prone to mental disorders. For example, public health messages tend to promote differences, rather than continuities, between those with mental disorders and those without. The 'stress' model also implies that anyone can develop a mental illness when faced with unusual threatening circumstances or demands. It is therefore more socially inclusive ('normalising') and could make mental illness everybody's concern.
The aim of this research was to determine whether there was any difference in stigmatised attitudes towards a Aims and method Tackling discrimination, stigma and inequalities in mental health is a major objective of the UK government. The project aimed to determine the effect of presenting a person with a mental illness as having either a biological illness or a disorder that arose from psychosocial stress to a randomised representative panel of members of the general public. The 20-point Attitude to Mental Illness Questionnaire (AMIQ) was used to assess stigmatised attitudes.
Clinical implications There was no difference in the stigmatised attitudes towards a person with mental illness regardless of whether they were presented as biologically ill or as having an illness that was a response to psychosocial stress.