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1 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA The Effect of Social Support through Online Forums: Erasing the Stigma of Mental Health Disorders Scierra N. Bratton Queens University of Charlotte 2 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA Abstract In any given year, one in five adults in the United States will be diagnosed with a mental disorder (Kitchener and Jorm, 2013, p.3). Within that same year, a national survey found that 19.6 percent of adults (18 or older) experience a mental disorder. The percentage may not immediately alarm you, but the equivalent is 45.6 million people. Researchers are now working to figure out what hinders and what helps individuals with these disorders. Meanwhile, increases in social media use through the implementation of platforms such as Facebook, Twitter and Instagram have created a global reach and easier access via mobile devices to engage, discuss and connect. Research leans in two directions. On one end of the spectrum, researchers believe that social media can be helpful in mental health recovery, while on the opposite end of the spectrum the argument is that social media is a cause of increasing mental health issues. For example, data from the Office for National Statistics suggests that children who spend more than three hours a day on social media are twice as likely to suffer from mental health issues (www.ons.gov.uk., 2016). On the other hand, studies show that children and adolescents should decrease social media time, but it is increasingly difficult with devices such as cell phones and tablets. These studies argue that a decrease in social media time equals a decrease in mental health issues. These mobile devices allow for users to constantly stay connected without regard for face-to-face interactions. However, McNeil (2013) suggests that social media has the opportunity to provide an outlet for grief and pain, or an opportunity to receive social support that may not otherwise exist. By participating in social media platforms, I believe that users are able to freely and boldly ask for guidance and social support without the pressures of real life, face-to-face social interaction. Key words: health care communication ethics, mental health, stigma, social support, social media, forums, digital propinquity, grief, pain, acceptance 3 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA Mental Health Communication and the Role of Social Media This project will study the impact of communication on mental health, specifically in social media communities, to better understand how people use online forums to build social support. Mental health disorders are serious issues that many face today. Some may not realize that they have a disorder due to misdiagnosis or not being diagnosed at all. Furthermore, there is typically a negative stigma placed on individuals who have been diagnosed, leaving many hesitant to learn the facts. Those who live with mental illnesses typically recall feeling tainted or “less than” (Yeshua-Katz and Martins, 2013, p. 500). Many times these individuals are labeled as crazy, violent or even stupid, which makes those who have not been diagnosed hesitant to get checked, for fear of falling into the stigma. As technology advances every day, so does the use of social media as users have the ability to share what they want, whenever they want. Consumers are avidly using online forums as a means of a virtual support group to connect with friends, family, and strangers all over the world. The focus of this project is to discover if positive communication takes place via forums in an effort to encourage social support and effective communication about mental health. There are many studies that share research on social media and the idea that it is a helpful tool in mental health recovery. This paper will take a deeper look at how individuals’ usage of social media affects their communication, thereby, their well-being including their mental health. Today, social support extends further than the face-to-face communication scenario. The Digital Propinquity Theory is defined as people who are online and are uniquely able to form attachments and connections to others who they would possibly never “meet” otherwise (McNeill, 2013, pp.5-6). The introduction of social media has changed the concept of community by allowing users the ability to disregard the restrictions of time and space. Whether 4 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA near or thousands of miles away, loved ones and strangers alike have endless ways to connect via social media. McNeill (2013) explains that community has gradually expanded beyond geographical borders, becoming a combination of real as well as virtual spaces with collective and collected experiences being gained from these worlds (p. 7). With the advancement of technology and the increase in social media use, studies are being conducted to see how excessive this use is and how it is affecting users, mentally. Through extensive research of health communication, I hope to discover how social support through social media is utilized by individuals who live with mental health disorders. I will look at how users are communicating and building relationships with others who have mental health disorders if the communication assists users or hinders their attempts to gain social support. The intended audience for this project is anyone who has a diagnosed mental health disorder or anyone who has a loved one with a diagnosed mental health disorder. It is important that the audience becomes more self-aware of how they are communicating with their loved ones because once they are aware, they might be able to enhance how they communicate with them. The goal of this project is to shed light on how online forums might have the ability to erase the stigma on mental health. For this inquiry project literature review, I will focus on how social support via social media communication might optimistically affect individuals living with mental health disorders. I will discuss the stigma on mental health, the digital propinquity theory, health care communication ethics, and responsiveness for health care communication. By analyzing social media presence, I will hope to understand how individuals might competently utilize social media platforms as a positive means of social support. The final outcome of this project will be a thesis. 5 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA Literature Review Defining Mental Health In the Mental Health First Aid USA manual (2013), mental health is discussed on a continuum that ranges from having good mental health to having mental disorders. Someone who feels in control of their emotions with exceptional cognitive functioning and has positive interactions with others is considered an individual with good mental health. Those who embody these characteristics tend to perform well at work, in school, and in family and other social relationships. The authors of the manual define a mental disorder, or mental illness, as “a diagnosable illness that affects a person’s thinking, emotional state, and behavior and disrupts the person’s ability to work or carry out other daily activities and engage in satisfying personal relationships” (Kitchener and Jorm, 2013, p. 2). A few common mental health disorders include: anxiety disorders, major depressive disorder, substance use disorder, bipolar disorders, eating disorders, and schizophrenia. Historical Context In the early history of mental illness, many cultures believed it was a form of religious punishment or demonic possession (uniteforsight.org, 2012). Ancient Egyptian, Indian, Greek, and Roman writings categorized mental illness as a religious or personal problem. In the fifth century B.C., Hippocrates, a pioneer in treating mentally ill people, focused on changing a mentally ill patient’s environment or occupation or administering medications. During the Middle Ages, the mentally ill were believed to be possessed and these negative attitudes continued into the eighteenth century in the United States. This negativity lead to the 6 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA stigmatization of mental illness and unhygienic (as well as often degrading) confinement of mentally ill individuals (uniteforsight.org, 2012). This same stigma on mental health still lurks today still with dark portrayals and a negative attitude towards individuals living with mental health disorders. Stigma As the use of social media expands, it is becoming increasingly important to understand that although there are risks, users are also able to utilize these platforms for recovery and to challenge the stigma. Today, individuals with mental health illnesses are using social media for peer support, shared learning, and to decrease their feelings of isolation. While mental health patients are recognizing this positive impact, I believe it is important for mental health practitioners to be able to increasingly gain an understanding so that they can provide the proper support and care. Betton and Tomlinson (2013) write that “practitioners in health are slowly waking up to the potential of social media as a tool to facilitate and promote the social inclusion of individuals living with mental health problems” (p. 57). The authors explain that social media not only provides a space for people with similar experiences to connect, but it has the potential to reduce isolation. These platforms promote engagement in peer support and can create a positive outlook for individuals experiencing mental health issues. The term stigma is composed of a double perspective known as discredited and discreditable stigma. Discredited stigma is when the individual assumes his or her differentness is already known or is visible and discreditable stigma is when he or she assumes it is neither known by those present nor immediately perceived by them (Yeshua-Katz and Martins, 2013, p. 500). Individuals who do not have a solid social support system offline might turn to online support groups to fill the void of social and psychological needs. This can assist in compensation 7 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA for the lack of those resources in real life allowing these stigmatized individuals the benefits of joining a group of others who are similar. Some benefits include: feeling less isolated and different, disclosing a long secret part of oneself, sharing one’s own experiences and learning from others, and gaining emotional and motivational support (Yeshua-Katz and Martins, 2013, p. 501). Some communication issues that stem from stigma include: expressing feelings of hopelessness, change in normal emotional behavior, increase in substance abuse, withdrawing from family, friends and society, anxiety, agitation, trouble sleeping or excessive sleeping, and dramatic changes in mood (Kitchener and Jorm, 2013, p. 106). One way to avoid or help soothe these issues is by utilizing the concept of interpersonal communication. Interpersonal communication is described as the relational function of communication. According to Goffman, these “interpersonal rituals” reflect on one’s “abilities to send, receive and interpret messages that influence their self-images, relationships and the giving and receiving of social support” (Query and James, 1989, p.170). This explains individual’s varying abilities to communicate supportively with others and elicit social support during crises such as a mental breakdown. There are five components of interpersonal communication competence; affiliation/support, social relaxation, empathy, behavioral flexibility and interaction management. Affiliation/support allows people to feel connected and build an attachment or relationship with others while also providing the opportunity to give assistance in times of need, uncertainty, or triumph. Social relaxation allows a space for enjoyment in order to halt feelings of nervousness or worry. The ability to understand and share feelings of others describes the empathy component. Behavioral flexibility refers to the adaptive change in behavior in response to one’s communication environment. If ongoing behavior, including inactivity, is stopped or modified 8 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA then a new behavior is initiated. Finally, interaction management is a component assisting in improving skills such as productivity, handling conflict, personal improvement and teaching positive models of behavior. All of these components can be highlighted in social media forum use. Furthermore, interpersonal communication competence has three consistently identified dimensions in which the above mentioned components fall into. They are cognitive dimension, affective dimension and behavioral dimension. First, the cognitive dimension refers to the ability to receive, process, and send information along a continuum of social-to-task dimensions. Secondly, the affective dimension looks at the use of human communication to create, maintain, and terminate relationships. Finally, the behavioral dimension addresses how job-related information is communicated to one another (Query and James, 1989, p.171). These three dimensions provide insight into how interpersonal communication is categorized when studying individual’s interactions. Through practice of interpersonal communication, individuals are able to find closeness and comfort through asking questions and giving or receiving feedback. Stigma has the ability to change over time as new ways are discovered to discuss and become transparent about mental health. This communication should include those who are living with mental health disorders not only because they have first-hand knowledge, but because open communication provides an opportunity to cope as well. Digital Propinquity Theory Through use of social media, users build a sense of attachment to networks and groups, also known as projected communities. These projected communities cause the digital propinquity effect, which is defined as a closeness inhibited by digital means (McNeill, 2013, p.5). An example of digital propinquity could be communicating in a forum on Facebook that focuses on 9 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA support for individuals living with a mental health disorder. The concept of digital propinquity creates a strong sense of connection and attachment that these individuals may not physically receive. One example of this concept includes a recent Twitter rant by singer, songwriter, actress, and model Demi Lovato. Just after midnight on May 5, 2016, Lovato sent a series of tweets to her almost 36 million followers discussing her displeasure about the negative attitude still seen towards individuals with mental disorders. One of the tweets received over 20 thousand retweets (etonline.com, 2016). I believe this shows how social media forums allows its users to connect and share information efficiently. This means that Twitter’s platform might be a conduit for digital propinquity by allowing those who follow Lovato to feel a sense of closeness and provide social support to others by retweeting or loving the tweet. Since people connected on Twitter see retweets and reactions to tweets as being loved, social support might be produced. As a public figure, Lovato has a following that allows for increased visibility of her social media platforms, thus possibly increasing her influence on others, including those with mental health disorders. Celebrities are not the only ones who use Twitter and other social media as a platform to provide digital propinquity. A writer for NursingTimes.net (2013) shared an example of the need for support on social media when there is no one around. In the example, a mother tweeted “my daughter is having a bad panic attack, we r using paper bag but I can’t seem to settle her? She is so scared its horrible any advice?” (NursingTimes.net, 2013). The website shared that although the mother tweeted at 11:20 p.m., several nurses began retweeting her message and offering advice. The website also said that the mother later used Twitter to thank the community for their support and reported that people were checking on them days later. According to NursingTimes.net (2013), “This is where social media comes into its own: it provides an outlet 10 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA for grief and pain, or an opportunity to get support that may not otherwise exist – maybe it’s 3am and someone is in need of support, but doesn’t want to disturb their family or friends, or maybe they feel desperately alone but feel they can’t face people in the offline world”. Perhaps the flipside of utilizing social media as a means to isolate oneself from the physical world is to seek guidance and advice from those other than the ones you would otherwise see face-to-face. By participating in social media platforms, users are able to freely and boldly ask for guidance and support without the pressures of real life social interaction. The users who respond and provide the support gain a sense of increase in their self-worth and self-esteem by assisting others. NursingTimes.net (2013) exclaims that “knowing you’ve helped someone is a wonderful feeling and can be a real boost to mental well-being. We aren’t just limited to new kinds of social media, there’s a wealth of forums out there on all kinds of topics aimed at specific demographics”. One of these topics is mental health and there are many boards and forums for people with various conditions that are moderated by volunteers to ensure people who use them remain safe. Although social media is not recommended as a replacement for therapy, it can beneficially compliment treatment. It allows for individuals to show their independence as well as boost self-efficiency and self-esteem as a method of recovery. The digital propinquity theory is achieved when positive and effective communication takes place and responsiveness is achieved. I will discuss even more examples further in the project as I look at psychcentral.com. Psych Central’s website provides a wealth of information for anyone living with a mental health disorder or anyone who just wants to become more educated on the topic. For this project, I will place primary focus on the forums section of the website. There are over 400,000 members and over 425,000 threads throughout the forum. With over 5 million posts within the forum, I will 11 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA select the most applicable threads within a given time period that discuss topics such as stigma, social support, and provide examples of digital propinquity. Exploring these posts will allow for identification of positive communication and relationship building communication online. Research shows that positive communication and relationship building communication are key to creating an engaging and proactive space in online forums. With sixty percent of American adults and eighty percent of Internet users seeking health information online, they are no longer simply passive consumers of the content they seek. Internet users have become active producers as well, with social networking sites increasingly being used for venues of exchange of health-related information and advice Hether, Murphy and Valente, 2014, p. 1424). Attitude and behavior are crucial aspects of position communication and relationship building communication as it relates to social media use. Attitude is typically open minded and nonjudgmental in forums for mental health discussion providing a sense of closeness, acceptance, and tolerance. Behavior tends to mirror attitude based on the connections made and increase in comfort levels, creating a space for valid questions, advice, information, and social support. It is hypothesized that trust in social media and the perception of social support are positively associated with health outcomes (Hether et al, 2014, p. 1433). The foundation of health care is caring which includes sympathetic response to those who suffer. In Communication ethics literacy: Dialogue and difference, authors define responsiveness as the responsibility that meets the call of the Other, even when the call is unwanted (Arnett, Fritz, and Bell, 2009, p. 191). Typically, an individual who is actively participating in social media for purpose of social support is also actively seeking responsiveness from their connections online. Health care communication ethics is more than what happens to us. Rather it is in our response. Viktor Frankl’s notion of final freedom is a central idea to health care 12 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA communication ethics. In other words, when it seems you have reached a dead end, with no options, our final freedom is the key to unlocking what seems impossible. “The importance of response emerges from a pragmatic realization – when there is no longer an easy answer given to us, we must find a creative response that breaks free of our demand for options no longer available (Arnett et al, 2009, p. 195). This outlet of responsiveness is available to all through social media anytime, anywhere. Research question: How is social media used as a means of social support on mental health forums? Method This study will consist of a textual analysis of digital media conversations on a forum focused on topics surrounding mental health. The purpose of analyzing these text conversations will be to explore how use of online forums provides social support for individuals living with mental health disorders. The study will focus on one digital media forum: 1. psychcentral.com This digital media forum was chosen because it offers information at no cost, open areas online for individuals to discuss amongst one another various mental health issues and provides the opportunity to receive social support. I believe this website will provide data that I can use to answer my research question. In 2008, Psych Central was recognized on TIME.com as one of the best websites for its top mental health content and social media tools. TIME.com (2008) also recognized Psych Central for its simple quizzes and the “Ask the Therapist” and prescription rating sections. After reviewing the website, I found it “offers an array of in-depth content from news, book reviews, 13 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA resource links, clinical trial overviews, and quizzes. From bipolar disorder to sexual disorders, Psych Central is continually building upon its more than 13 years of serving the online community” (Psych Central, 2008). Founder and publisher, Dr. John Grohol shared that the website’s commitment is to providing people with trusted mental health information in an effort to help reduce the stigma associated with it. I believe this website can be used as a self-help tool that allows members to be a part of support groups. A positive impact of social media is the ability to connect with others and gain support in a non-judgmental environment. Psych Central (2008) announced that “each month more than 650,000 people visit Psych Central, to connect with others, read about various mental health concerns, take assessment quizzes, and more”. Sites that provide services and forums for social media users, such as Psych Central, may help to break down the barriers of stigma often associated with mental health concerns by bringing trusted resources to the Internet. Procedure A textual analysis will provide the opportunity to gather information about sense-making practices, look at how similar or different the sense-making practices people use can be and provide a better understanding of social support by examining limitations and possible alternatives to stigma, isolation, grief, and pain (McKee, 2003, p. 14). For the purpose of this study, I will focus solely on conversations for textual analysis to determine if there are benefits of providing social support online. The conversations from forums are worthy of analysis because the content provides insight and might reveal that online forums provede a positive outlet that can often be overlooked as a benefit of social support. I will collect posts in the Relationships and Communication forum to use as my data for this study. 14 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA Sample To conduct digital research, I chose the website psychcentral.com, the internet’s largest and oldest independent mental health social network (psychcentral.com, 2016). Psych Central provides a wealth of mental health information, emotional support, and advocacy to over seven million people worldwide. Celebrating its twentieth year online and named one of the “50 Best Websites of 2008”, one of Psych Central’s many features includes two online community forums (psychcentral.com, 2016). I will focus my data collection to include conversations from April 2016 through May 2016 on the Relationships and Communication forum to determine if of ongoing conversations online provide social support. I will look closely at the Relationships and Communication forum which includes 237 threads from April 1 to May 31 which include a varying numbers of replies, from hundreds to thousands. The goal will be to determine the number of posts that appear to be written with the intention of seeking social support. For example, one post’s subject line is “Feeling so alone”. I will read through all of the replies to examine how other users respond in an effort to comfort the initial poster and provide advice on coping with feelings of isolation. I will highlight the best replies in research and throw out any duplicate replies. Criteria for highlighting selected posts and replies will include recurring words and phrases that may be interpreted in thematic findings. Data Analysis Selected texts will be analyzed using several components. First, each text will be examined by deciphering whether or not a particular mental health disorder was defined or described. For example, whether or not the text generally discussed mental health or if a specific disorder was articulated or a lens implied on any individual disorder. Was the information within the conversation clearly and thoroughly given and supported by the author? Furthermore, within 15 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA each conversation (or thread), what are the responses provided to the initial post? Are the conversations more negative or positive? What might the continuous conversations provide to fellow authors and readers? Is there a method of support and coping provided? I will identify key words and phrases used within the conversations related to mental health will include symptoms, challenges, stigma, coping, care, and support. From this, I hope to determine the implications of social support. Owen (1984) discusses thematic interpretation techniques including recurrence, repetition, and forcefulness (p.275). From the analyses of these themes, I should complete the goal of this study, which is to discover how online forums are utilized. Are they a means of social support? Challenges and Limitations The purpose of this study is to gain an insight into the communication barriers of individuals living with mental health disorders. The study might have data limitations because it is being collected from sources who are not healthcare professionals. The data will be focused more on personal experience and suggestions as opposed to science or research based information. Therefore, the data collected will be provided on a case-by-case basis. Also, different individuals will have experienced different issues, side effects, and outcomes which could affect the outcome of the data. Researcher bias may be another limitation, as I will be the only person interpreting the themes. A challenge may also be the amount of data collected. However, this study will attempt to shed light on the possible benefits of utilizing online forums as a means of social support by looking at the themes throughout posts, and their replies in the Relationship and Communication thread on Psych Central’s website. 16 Running Head: MENTAL HEALTH COMMUNICATION AND SOCIAL MEDIA References Anderson, I. (2011). The Uses and Gratifications of Online Care Pages: A Study of CaringBridge. Health Communication, 26(6), 546-559. Arnett, R. C., Fritz, J. M. Harden & Bell, L. M. (2009). Communication ethics literacy: Dialogue and difference. Los Angeles: Sage. Betton, V., & Tomlinson, V. (2013). Social media can help in recovery - but are mental health practitioners up to speed? Mental Health and Social Inclusion, 17(4), 215-219. Braithwait, D., Waldron, V., & Finn, J. (1999). 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