Is the internet good for mental health?

Online information, extreme communities and internet
therapy:
VAUGHAN BELL
Institute of Psychiatry, King's College London, De Crespigny Park, London, UK
Abstract
Background: Questions have been raised about the internet's effect on mental health, although no
principled review has yet tackled the issue.
Aims: To examine the effect of the internet on mental health.
Method: Literature review.
Results: The internet is typically discussed as if it were a set of activities when it is actually a medium
upon which various activities can occur. It is, therefore, neither ``good'' nor ``bad'' for mental health,
although speci®c activities may have an in¯uence. The standard of mental health information on the
internet is probably equivalent to the mainstream media, although overall it still remains poor. The
concept of ``internet addiction'' looks increasingly invalid, although it is likely that depressed or
isolated individuals are more likely to focus on certain activities to excess. A number of ``extreme
communities'' have formed online, such as pro-anorexia, pro-suicide, pro-amputation and likely-
psychotic groups. These serve to provide support, outside a medical and social mainstream that ®nds
their beliefs and behaviours unacceptable. A review of preliminary randomized controlled trials shows
online therapy to be effective for many disorders.
Conclusions: Mental health professionals are advised to lead the creation of online treatments and
information. Clinical recommendations for the use of the internet are offered.
Declaration of interest: None.
Keywords: Internet, online, extreme communities, cybertherapy, mental health, e-therapy
Introduction
The internet is now ubiquitous. Its popularity stems from the fact that it is, at its core, a
medium of communication for electronic devices. This subtlety is often lost in debates about
the internet, where it is usually discussed as if it were a speci®c activity or set of software,
when, in fact, these are simply resources that use the internet to communicate. This is also a
crucial point when trying to determine the effect of the internet on mental health, as any
psychological consequences will depend on the activities that the technology enables, the
attributes of the user, and how the two interact (Joinson, 2003). Conceivably, two different
computer-enabled activities could both use the internet as a medium of communication, but
share no common psychological attributes.
Correspondence: Vaughan Bell, Institute of P sychiatry, K ing's College London, P sychology D ept Box 7 8 , D e Crespigny P ark,
London S E5 8 AF , UK . E-mail: Vaughan.Bell@ iop.kcl.ac.uk
J ournal of Mental H ealth,
August 2007 ; 1 6 (4 ): 4 4 5 ± 4 5 7
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This implies that there is no general ``psychology of the internet'' (no more than there is a
``psychology of radio waves'' or other medium of communication) to be understood and
applied by clinicians wanting to prevent or alleviate mental distress. Therefore, the internet
can only be understood in terms of speci®c applications, pieces of software or activities that
take place upon it. Although this means that there can be no general consensus about
whether the ``internet'' is inherently good or bad for mental health, this does not deny that
there are popular applications and activities on the internet which are likely to have shared
features and speci®c psychological effects. R elatively little research has focused on these,
despite the fact that they are the subj ect of common concern and will undoubtedly play an
increasingly important role in the lives of people across the world.
M ethod
This review focuses on recent research on both the interaction between common internet
activities and mental health, and on the current state of online interventions. Notably, the
review is selective, in that it focuses on studies which are likely to be of most interest to
clinicians. It preferentially covers studies that have examined traditional mental health con-
cerns and tends not to include studies of wider issues for which mental health professionals
may nonetheless have an interest (for example, the understanding of general health infor-
mation online, or the impact and management of chronic physical conditions, to name but
two) unless they provide useful context for the discussion.
F urthermore, the review aims both to highlight concerns not previous considered, and to
``plug gaps'' in the existing literature and, hence, is not intended as a systematic review of all
individual studies on the internet and mental health. W here current and comprehensive
review papers of a relevant area already exist, these are discussed in preference to a review of
individual papers. Most notably, the research into online therapy for anxiety disorders is
covered only very brie¯y, as an excellent review of this area has recently been provided by
Andersson et al. (2005 a). However, where no such current reviews exist for a particular area,
individual studies are reviewed to provide an overview of the current state of research.
W ithin this remit, however, this review provides speci®c evidence-based recommenda-
tions and advice for clinicians wanting to understand the internet to improve mental health
care for clients, to design effective internet-based information resources and interventions,
and to enhance their own use of internet technology.
M ental health information on the internet
It is estimated that about 5 % of web searches are health-related (Eysenbach & K ohler, 2004 )
despite the fact that the quality of information is mixed and users have limited competency
in ®nding and accessing information when online (Morahan-Martin, 2004 ). O ne concern
commonly raised by professionals is that anyone can create internet content, and so there is
little quality control. This is perhaps less of a concern than it ®rst seems, however, owing to
the fact that search engines often use a measure of how many other web pages link to a
speci®c page (a measure of popularity) as a signi®cant factor when ranking pages, so
obviously false or eccentric information is unlikely to be immediately encountered when
looking for general health information. Indeed, the rankings given to depression information
websites by the popular search engine G oogle have been reported to largely correlate with
ratings from a standardized tool for assessing quality of information (Grif®ths &
Christensen, 2005 ), suggesting that this process of online ``natural selection'' is quite effec-
tive in ®ltering out the most ¯awed information from general view.
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A further concern is that mental health information on the internet is generally considered
to be of a low standard. S tudies have reported varying, but an overall level of poor quality
information for disorders such as depression (Berland et al., 2001 ; Grif®ths & Christensen,
2000, 2002; Lissman & Boehnlein, 2001 ), schizophrenia (K isely et al., 2003), attention
de®cit hyperactivity disorder (K isely et al., 2003) and eating disorders (Murphy et al.,
2004 ). Nevertheless, this is not necessarily a feature of the internet, as mental health
information in the mainstream media has found to be similarly lacking (Christensen &
Grif®ths, 2000; Inch & Merali, 2006 ).
S tudies which have examined how people evaluate health information online have
typically reported that users will judge quality by the endorsement by a government or
professional body, ease of understanding, and perceived quality of presentation
(Eysenbach & K ohler, 2002; S chwartz et al., 2006 ), suggesting that users deploy some
critical evaluation when accessing information. It is perhaps worth noting that many of the
high-ranking mental health information websites are sponsored either directly or indirectly
by pharmaceutical companies and so will undoubtedly be rated as reliable sources by users
(trust in drug information from traditional media such as television or print media is know to
transfer to internet presented material; Menon et al., 2002) but are also unlikely to be free
from bias. The few studies that have directly addressed this issue have found that
pharmaceutical company websites have signi®cant bias in presenting information about
antidepressant medication (Graber & W eckmann, 2002), and in a recent study by Lissman
and Boehnlein (2001 ), the lowest quality information on internet depression sites was found
on sites from pro®t-making companies of various types, rather than from not-for-pro®t
organizations.
Y barra and Eaton (2005 ) have recently reviewed the literature on online support
groups and note that they are both popular sources of information and support for
many internet users. These are typically user-led and tend to be based around bulletin
boards, email distribution lists or other types of discussion system. O nline mental
health support groups may have a number of advantages when compared with similar
of¯ine groups. They are known to have a high level of information exchange (with the
bene®t of being hosted on the same medium upon which a large amount of infor-
mation is easily referenced) and participants report they are more likely to discuss
problems they do not discuss face-to-face (K ummervold et al., 2002), probably owing
to the high level of self disclosure found in such groups (F infgeld, 2000; Haker et al.,
2005 ). R esearch has also found similar effects for groups that involve or are designed for
carers of people with mental health issues (P erron, 2002; S charer, 2005 ). In a
prospective study, Houston et al. (2002) found that users of an online depression
support group had lower social support than comparable samples of patients from
primary care, but that heavy users of the group were more likely to show a resolution of
their depression over time. The wider effect of such groups has been dif®cult to judge,
however, largely owing to a lack of principled research into the area. O ne recent review
found little evidence for a consistent positive effect of such groups on depression or
social support (Eysenbach et al., 2004 ), although found little evidence that any groups
were harmful.
An important implication of these ®ndings is that clinicians should be aware of the maj or
types and sources of information online, and be ready to recommend accessible and high-
quality online resources. Clinicians are increasingly being presented with information
gleaned from the internet by their clients, and being able to direct a client to more accurate
information, rather than discouraging use of a potentially useful resource, is likely to be a
fruitful strategy.
Mental health and the internet 4 4 7
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P athological internet use
Two main strands have permeated the literature on pathological internet use. O ne is on
compulsive internet use or ``internet addiction'', the other is on psychopathological effects
(typically depression or isolation) related to time spent online.
O ne of the dif®culties with the concept of ``internet addiction'' is that it is rarely made
clear exactly what an individual is supposed to be addicted to, in light of the fact that the
internet is a medium that can support a number of diverse activities, implemented in a
variety of ways, across a range of devices. The proposed criteria for internet addiction (e.g.,
Beard & W olf, 2001 ; K o et al., 2005 ; Y oung, 1 9 9 8 ) or pathological internet use (Morahan-
Martin & S chumacher, 2000) typically make reference to ``using the internet'' or ``spending
time online'' without reference to any speci®c activity. These criteria suggest the bizarre
possibility that one can be addicted to a medium of communication rather than an activity,
whereas the accepted criteria for other behavioural addictions (such as D S M-IV pathological
gambling) do exactly the reverse, specifying the activity but not the medium. Grif®ths (1 9 9 8 ;
1 9 9 9 ) has also noted that current criteria do not represent the core psychological elements of
addiction, namely salience, mood modi®cation, tolerance, withdrawal, con¯ict and relapse
(Grif®ths, 1 9 9 6 ). This suggests that the validity of a general `internet addiction' is
increasingly doubtful, although it is still feasible that individuals might perform speci®c
internet activities to excessive levels.
S tudies which have speci®cally reported the online activities of users who are deemed to
have some form of pathological internet use typically suggest that gaming, chat and erotica
are the most signi®cant (Chak & Leung, 2004 ; Chou & Hsiao, 2000; Leung, 2004 ;
Meerkerk et al., 2006 ; Morahan-Martin & S chumacher, 2000; S imkova & Cincera, 2004 ). It
is also notable that those classi®ed as ``pathological internet users'' report lower self-esteem
(Niemz et al., 2005 ), increased loneliness (Nalwa & Anand, 2003; Nichols & Nicki, 2004 ),
increased depressive and suicidal ideation (K im et al., 2006 ), increased shyness and external
locus of control (Chak & Leung, 2004 ). As these studies are largely cross-sectional,
however, it is dif®cult to infer a direction of causality, and it is just as likely that anxious,
lonely or depressed people might attempt to alleviate their distress by seeking online
resources for entertainment, social interaction and sexual grati®cation.
S tudies on general internet users seem to support this position. Although initial work
suggested that time spent online was correlated with a small but signi®cant increase in
loneliness and depression (K raut et al., 1 9 9 8 ), subsequent replications and extensions found
the reverse (Howard et al., 2001 ; Moody, 2001 ; W astlund et al., 2001 ) and a follow-up to
the original K raut et al. study found the negative effects were no longer present and that, in
contrast, internet use was generally associated with positive effects on communication, social
involvement, and well-being (K raut et al., 2002). A key ®nding from this latter study was
that extroverts generally showed a positive relationship between internet use and social well-
being measures, whereas introverts showed the reverse ± reporting an increase in isolation
and loneliness. It is still not clear why this might be the case, although it has been suggested
that the internet might provide tools to ``amplify'' predispositions (Joinson, 2003), so that
extraverts can meet more people and socialize, while introverts can keep them at a distance.
These ®ndings come with some important caveats, however. O ne of the constant features
of the internet is change and one of the most signi®cant developments that has occurred
since these studies were published is the massive popularity of websites and software which
integrate social cooperation into knowledge-based tasks which were previously individua-
listic and didactic (such as distributing images, listing favourite links, and creating web-
based information). This new approach to online activities has been christened ``W eb 2.0''
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(O 'R eilly, 2005 ) to denote its fundamentally different approach, and it is not clear how such
activities might differentially in¯uence users' well-being, owing to the fact that social
interaction is becoming an increasing part of everyday internet activity.
Extreme communities
O ne feature that has garnered relatively little attention in the clinical research literature is the
existence of what might be termed ``extreme communities''. O wing to the dif®culty with
which material can be effectively censored or suppressed online, views considered extreme
or unacceptable to the mainstream can be expressed relatively freely, with online com-
munities often formed by those who share similar opinions. S ome of these are of particular
interest to mental health professionals, as they attempt to reframe what would otherwise be
classi®ed as ``mental disorder'' in an entirely different light.
The ``pro-anorexia'' or ``pro-ana'' movement (also ``pro-bulimia'' or ``pro-mia'') has been
one of the most publicized examples where websites and online communities promote
anorexia and related eating disorders as a ``lifestyle choice'' rather than a medical disorder
(D avies & Lipsey, 2003). O n some websites, participants upload pictures of particularly thin
celebrities or particularly obese people as ``thinspiration'', or even pictures of themselves for
others to comment on and encourage. Tips on effective dieting, including the use of weight-
loss drugs and advice on how to avoid detection by professionals and family members when
skipping meals, are swapped between participants. The existence of ``pro-ana'' websites was
the subj ect of intense press attention during 2000 ± 2001 (even meriting a feature article in
T ime; R eaves, 2001 ) that suggested that these sites might be promote or maintain eating
disorders in vulnerable adolescents. As anorexia has one of the highest mortality rates of any
psychiatric disorder (Birmingham et al., 2005 ) an obvious concern might be that such
communities would provide high-levels of social support for an anti-medical explanatory
model that would decrease recovery rates and potentially lead to the death or injury of its
participants.
R ecent research on ``pro-ana'' websites, however, has uncovered a more complex and
nuanced account of such communities that suggests that they exist for more than the
reinforcement of restricted eating behaviour. A recent linguistic study on the self-
presentation of pro-anorexics by Lyons et al. (2006 ) reported that ``compared with
recovering anorexics, the word use of pro-anorexics indicated a more pronounced hedonic
focus on positive emotions and the here and now, reduced level of cognitive processing, and
a lower degree of self-preoccupation'' suggesting that participation may have signi®cant
anxiety managing effects for the individuals concerned. An online ethnographic study by
F ox et al. (2005 ) came to similar conclusions and suggested that the community offered its
participants a safe and positive place to gain further insight into their condition, away from
the judgement, gaze and scrutiny of parents, boyfriends, husbands and the medical
profession, ®ndings similarly echoed by Mulveen and Hepworth (2006 ).
O f particular interest to those familiar with cognitive behavioural approaches to treating
compulsive behaviour might be the personi®cation of anorexia or bulimia as ``Ana'' or
``Mia'', with some pro-anorexics even going as far as referring to Ana as a ``Goddess'' or
``F riend'' (D ias, 2003). P ersonifying obsessions and compulsions as (for example) a ``bully''
has proved a successful technique for empowering clients to resist intrusive thoughts (Clark,
2003) and it is interesting that this community has used an almost identical technique to
personify such behaviour as a companion or ideal. Therapists may need to be aware that
such constructs may provide strong psychological motivation to maintain pathological
behaviour and be ready to detect and counter them.
Mental health and the internet 4 4 9
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This process of building and reinforcing an alternative framework for behaviour
pathologized by mainstream medicine and society is not solely restricted to those who
might otherwise be considered to have an eating disorder. Bell et al. (2006 ) used hyperlink
network analysis to examine the social network of a likely-psychotic group of individuals
who form a cohesive and dynamic online community. The participants rej ect any medical
explanation of their experiences and instead argue that they are the subj ect to ``mind
control'' technology (such as top secret ``thought control'' weapons), collectively
gathering and referencing a signi®cant amount of online material in support of their
assertions. Again, therapists should be aware of the amount of information available on the
internet that aims to justify almost any sort of conspiracy theory, fringe belief or
anomalous experience. The de®nition of a delusion as a belief not adequately justi®ed by
supporting evidence may have to take into account that anyone who spends 30 minutes
online can ®nd plenty of ``justifying evidence'', regardless of its validity or source. It is
notable, however, that the internet can also be used as a data-gathering tool for use in
``reality testing experiments''. Both Bell et al. (2005 ) and D uggal et al. (2002)
reported the use of web searches for testing predictions, as part of a successful cognitive
behaviour therapy (CBT) programme for two individuals who had delusions about the
internet.
Nevertheless, extreme communities may also focus on more ``practical'' issues, rather
than simply attempting to provide alternative frameworks for explaining mental distress. The
phenomenon of internet suicide pacts, where individuals who do not wish to die alone
organize a group suicide, has raised concerns that passive individuals may be more likely to
take their own lives owing to group conformity effects (Lee et al., 2005 ; R aj agopal, 2004 )
and that the availability of information on effective methods might lead to an increase in
completed suicides (Alao et al., 1 9 9 9 ; Becker et al., 2004 ; P rior, 2004 ; Thompson, 1 9 9 9 ;
2001 ).
W hile these concerns largely centre on people who might already be suicidal, Becker and
S chmidt (2004 ) have highlighted research indicating that media reporting of suicide has
been found to have a signi®cant effect on adolescent suicide rate (S chmidtke & S challer,
2000), something which has been tackled by the implementation of reporting guidelines for
professional media outlets. As the internet is not necessarily subj ect to such regulation,
however, Becker and S chmidt voice concerns that suicide or parasuicide could be increased
by ``grassroots'' internet publicity of particular suicide cases.
Unfortunately, the maj ority of research on suicide and the internet is in the form of
anecdotal case reports with little in the way of controlled or principled studies. It is dif®cult,
therefore, to determine whether the use of the internet by potentially suicidal people should
be considered entirely problematic. Indeed, a report by Barak (in press) on an Israeli web-
based suicide prevention initiative (called S AHAR ) has noted that a number of suicidal
individuals have been attracted to the website and helped, either when intending to commit
suicide or actually in the process of trying.
As suicide and parasuicide are tragically common, it is, perhaps, more likely that online
interventions will reach potentially suicidal individuals, than in cases of less common but
no less destructive behaviours. O ne curious example in this regard is a case report of a
middle-aged male who self-amputated both legs after expressing a life-long desire to be an
amputee (a condition named apotemnophilia). The man in question reported that his
participation with other members of an online discussion group (for those wanting to be
amputees) ``deepened his motivation, developed the means, and ®nalized his determina-
tion to act on his desire'' (Berger et al., 2005 ). Although the role of the internet in
enabling such behaviour remains unclear from a single case study, the fact that such an
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eccentric and potentially self-injurious desire has a supportive online community suggests
that an individual interested in almost any behaviour, no matter how unconventional, is
likely to be able to ®nd like-minded others. Indeed, W allace (1 9 9 9 , p. 7 9 ) has noted that
``on the internet, people who share your interest and lean in the same direction as you are
just a few keystrokes away, regardless of the issue's obscurity, social desirability, or
bizarreness''.
There are a number of factors that might explain why ``extreme communities'' form on
the internet. The maj ority communicate through text-based mediums, such as email lists,
newsgroups or web-based bulletin boards that provide users with visual anonymity. A study
by W alther (1 9 9 5 ) found that exchanges between participants were rated as more
affectionate, more socially oriented (as opposed to task oriented) and more relaxed during
text-based than face-to-face communication. Examining similar online exchanges, S pears
et al. (1 9 9 0) found that visual anonymity caused polarisation of attitudes in participants, and
a strengthening of group norms when group identity was salient. It is likely, therefore, that
participation in such communities in strongly reinforced by both the overt social support for
otherwise socially unacceptable beliefs and behaviours, and covertly reinforced by the way in
which the medium facilitates the strengthening of group norms and mediation of affect.
Joinson (2003) has argued that there is a cyclic process at work, in that users select
media based on preferences and communicative agendas (e.g., need for visual anonymity,
ease of use) and then experience secondary psychological in¯uences on their behaviour
because of the (perhaps unexpected or unnoticed) effect of the media on their interaction
with others.
W hat this does not explain, however, is how individuals come to create or ®nd niche
communities centred on potentially pathological desires. O ne clue is from a seminal article
by Anderson (2004 ; see also Anderson, 2006 ) who described the ``long tail'' business model
(referring to the tail of a power-law distribution) adopted by popular online retailers. It is
based on the premise that total demand for non-mainstream products outstrips demand for
mainstream products, and that the internet reduces both the costs of distribution for the
retailer, and the costs of ®nding a particular product for the consumer, to the point where a
market for even wildly non-mainstream products becomes viable. Applied to people with
unpopular, marginalized or pathological desires, the costs of expressing such desires and
®nding like-minded others in the of¯ine world are very high, as social disapproval,
discrimination or even the applications of sanctions are common. O n the internet, however,
the costs are vastly reduced both in terms of advertising one's preference, and for seeking
others with similar preferences. Hence, a ``long tail'' of communities catering for those with
anomalous desires and behaviours has emerged (although most are not as extreme as the
ones mentioned here).
A typical reaction to the existence of such extreme communities is censorship, as occurred
when ``pro-ana'' websites were widely publicized (R eaves, 2001 ). It is perhaps worth noting
that effective censorship on the internet is near impossible, and that such attempts will
prevent only technically naÈõ ve users from accessing such content and communicating with
others. A more viable option is to provide alternative high-quality mental health information
that is easily accessible (i.e., ranks highly in internet search engines and is well-presented) so
those looking for information about their source of mental distress will encounter this
information before sites on the ``long tail''. In light of Joinson's (2003) model that suggests
that users with mental health issues may select the internet as a medium that ful®ls certain
needs, online information and support must be designed speci®cally to ful®l these needs,
and fringe communities need to be understood, as
( Fucking hell Jeff I am not a robot, Fri 14 Jun 2013, 11:11, 3 replies, latest was 12 years ago)

woah check em

(katie hopkins telling it where its at, Fri 14 Jun 2013, 11:18, Reply)

angry at the internet lols

(#1, Fri 14 Jun 2013, 11:54, Reply)

hahahahaha yeah

(katie hopkins telling it where its at, Fri 14 Jun 2013, 11:59, Reply)

hahahaaha
'Two main strands have permeated the literature on pathological internet use. One is on compulsive internet use or ``internet addiction'', the other is on psychopathological effects (typically depression or isolation) related to time spent online'

A third strand, concerned mainly with 'dubs', 'tekkers' and 'checking 'em' has also emerged in recent years.
( Monty Boyce, My cheese game is strong, Fri 14 Jun 2013, 11:21, Reply)

The last bit is priceless
'users with mental health issues may select the internet as a medium that fulfils certain needs'

They sure do
( Monty Boyce, My cheese game is strong, Fri 14 Jun 2013, 11:23, Reply)