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Running Head: SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 1
Social Media and Mental Health Intervention: A Collection of Case Studies
Emma Batten, B.A. (Hons)
In consultation with Constable Scott Mills and Anne Marie Batten RN
Success and Safety Relationships and Technology Centers (SSRTC)
April 19, 2013
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 2
Literature Review
Barriers to Treatment
In recent years, the Canadian mental health system’s effectiveness has been called into question.
Numerous studies have identified treatment barriers. Such barriers unintentionally deny a patient from
accessing treatment. The Mental Health Commission of Canada has stated that, “Only one in three people
who experience a mental health problem or illness- and as few as one in four children or youth- report
that they have sought and received services and treatment” (Mental Health Commission of Canada, 2012,
p. 12). This is atypical of other health conditions and suggests an inadequacy in current mental health
services.
A Canadian study conducted in 2006 by Wang provides some useful statistics. Of the 4094
participants in this study, 21.6% reported that they required assistance for mental health or substance
abuse issues and did not receive it (Wang, 2006). These participants were also asked to provide reasons
for their lack of treatment. Of this 21.6%, 794 participants reported various treatment barriers (Wang,
2006). However, the treatment barriers commonly reported were related to acceptability rather than
accessibility (Wang, 2006). In other words, individuals chose to avoid treatment because of perceived
social stigma.
With regards to treatment barriers, there are two distinct categories. These categories are referred
to as acceptability barriers and accessibility barriers. Acceptability barriers refer to issues of stigma
and social acceptance. On the other hand, accessibility barriers refer to the availability and accessible
nature of services. In the case of Wang’s study, participants reported issues of social acceptance as their
perceived treatment barriers. Thus, availability of mental health services was not perceived as an issue.
The Mental Health Commission of Canada has supported this idea. According to their report,
stigma and the fear of being labeled prevent many individuals from seeking mental health services
(Mental Health Commission of Canada, 2012). In addition, some people are unaware that they have a
mental health problem, which can result from either a lack of knowledge or the symptoms of the mental
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 3
disorder itself (Mental Health Commission of Canada, 2012). Interestingly, other Canadian studies have
identified lack of knowledge as a barrier to treatment.
A Canadian study in 2007 found that low-income individuals who had not completed high school
were the most likely group to report acceptability barriers to mental health care (Steele, Dewa, & Lee,
2007). With regards to treatment barriers, low education levels are strongly correlated with perceptions of
stigma. This is consistent with the idea that a lack of knowledge, or education, can serve as a treatment
barrier. An individual may be unaware that they require treatment.
In a study based on Ontario’s health care system, patients reported financial barriers to treatment
(Sareen, et al., 2007). This is consistent with another Canadian study conducted in 2006 (Steele, Glazier,
& Lin, 2006). High-income respondents are more likely to receive mental health services (Steele, Glazier,
& Lin, 2006). Since Canada’s health care system is universally funded, it is possible that individuals of
lower socioeconomic status are not receiving treatment due to a lack of education. This supports the
notion that education and mental health treatment are linked. Within Canada, there is a need for increased
outreach to low-income individuals (Sareen, et al., 2007).
This presents an interesting challenge for Canada’s mental health system. The prevailing issue is
not availability of resources. Rather, there appears to be a fundamental disconnect between patients and
available services. To date, there are a significant percentage of mentally afflicted patients who are not
receiving treatment. This has serious implications, since an untreated mental illness affects an individual’s
quality of life. Also, on a macro level, untreated mental illness can have a negative effect on the health
and productivity of a community (Sareen, et al., 2007).
Social Media Use
Before discussing the relationship between social media and mental health services, it is
important to note the growing use of social media in general. In the last decade, social media has become
increasingly popular. According to Ipsos’ most recent report, more than one-half (62%) of all Canadians
have visited or browsed a social networking site (Ipsos Reid, 2012). This is higher than ever before. This
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 4
increase in social networking may be due to an increase in mobile internet access.
Currently, 86% of Canadians have access to the Internet (Ipsos Reid, 2012). There has not been
an increase in Internet access over the past few years (Ipsos Reid, 2012). However, 37% of Canadians
now have mobile Internet access (Ipsos Reid, 2012). This is a dramatic increase from Ipsos’ 2001
statistics, where only 5% of participants possessed mobile Internet access (Ipsos Reid, 2012). Overall,
the increase in availability of mobile internet access may be responsible for the increase in social network
use.
Of the Canadians who have visited a social networking site, approximately half report visiting a
site on a daily basis (Ipsos Reid, 2012). This is an increase compared to recent years, and suggests that
participant’s reliance on social networking has increased. In fact, 41% of Canadians felt that they
communicated with people online more than offline (Ipsos Reid, 2012). Thus, it would appear that social
media has become a tool for individuals to communicate and relationship-build.
According to Ipsos, the most popular social networking sites appear to be Facebook, Twitter,
Linked-In (Ipsos Reid, 2012). With regards to Twitter, research has shown that individuals are using the
site to share information and meet people (Johnson & Yang, 2009). A study conducted by Chen in 2011
seems to expand on this notion. Chen found that, through Twitter, individuals can gratify the basic human
need to connect with other people (Chen, 2011). Twitter appears to be a medium that people actively seek
out in order to connect with others (Chen, 2011). By facilitating interpersonal communication, social
networking sites can improve an individual’s psychological well-being.
There is evidence to support the idea that social networking can have psychological benefits.
Using social media, individuals can express their feelings and share ideas. Social networking can also be
used to relationship-build and connect with other individuals or groups. Communication plays a vital role
in integrating people into their communities (Kontos, Emmons, Puleo, & Viswanath, 2010). Such
integration can be achieved by helping to build support, maintain ties, and promote trust (Ackerson &
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 5
Viswanath, 2009). Through social networking sites, individuals can reach out and establish meaningful
social connections.
Medical Uses for Social Media
Because social media is used for relationship-building and information-sharing, many health
programs have begun to connect with individuals through social networking sites. Social networking
offers the potential for mass collaboration, which is useful from a health standpoint. Studies have shown
that there is an absence of inequalities with regards to social network use.
With regards to Internet access, there are significant disparities among racial, ethnic and social
groups. Generally speaking, there are sociodemographic inequalities when it comes to Internet access.
However, it has been shown that, once Internet access is gained, there is consistent use of social
networking sites regardless of any sociodemographic characteristics (Kontos, Emmons, Puleo, &
Viswanath, 2010). Thus, there is an absence of inequalities with regards to social networking. This
suggests that social networking sites might be an effective tool for sharing health information. For
example, there has been success with sharing public health interventions on social media sites (Kontos,
Emmons, Puleo, & Viswanath, 2010). Through social media, health care services can communicate with
many different groups of people.
However, many workplaces do not allow their employees to engage in social media. There has
been research to demonstrate that social media can enhance a workplace’s performance, specifically
within the health care field. A good example of this is the Mayo Clinic in the United States. The Mayo
clinic has embraced social media and has become very popular online. The Mayo Clinic has the most
popular medical provider YouTube channel and nearly 200 000 Twitter followers (Cleary, 2011). The
Mayo Clinic has been able to use social networking to share health information and spread awareness.
In the past decade, there has been an increase in online health information. Recently, this digital
health information has become more mobile (Della, Eroglu, Bernhardt, Edgerton, & Nall, 2008). A good
example of this is the Apple Store, also referred to as iTunes, which sells digital media online. iTunes
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 6
provides free podcast sessions from numerous health information sources (Della, Eroglu, Bernhardt,
Edgerton, & Nall, 2008). This allows individuals to download health information right to their mobile
devices. Many large health institutions are also offering podcasts and RSS feeds directly from their
respective websites (Della, Eroglu, Bernhardt, Edgerton, & Nall, 2008). There has been a dramatic
change in the way that individuals receive and share health information. As a society, reliance on digital
information is rapidly increasing. Many medical institutions have responded by offering online health
care information.
Social Media and Mental Health
Within the mental health field, it is believed that social media use can make a significant
difference. As discussed previously, there are significant treatment barriers within the mental health
system. Many individuals do not receive treatment for their symptoms due to acceptability barriers.
However, social media allows for individuals to interact with mental health supports in a comfortable
environment. As previously stated, 41% of Canadians currently communicate with individuals online
more frequently than offline (Ipsos Reid, 2012). For individuals who prefer online communication, social
media could serve as an effective tool to provide mental health counseling. Also, the portability of social
media allows for rapid, unencumbered communication.
To date, there is not a lot of literature examining the effectiveness of mental health case
management through social media. However, a Canadian study in 2012 has demonstrated that there is a
desire for online mental health counseling services (Bender, et al., 2012). This study involved testicular
cancer survivors, who were recruited through the Princess Margaret Hospital. Of the participants who
used social media, more than half (60%) expressed a desire to engage in online supports (Bender, et al.,
2012). Furthermore, 26% of the social media using participants admitted to using online communities for
support related to testicular cancer (Bender, et al., 2012). Thus, individuals were using the Internet to
supplement their treatment process. By reaching out through social networking, testicular cancer
survivors were able to satisfy psychosocial needs.
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 7
Social media can also serve as an effective tool to communicate public mental health information.
For example, in post-911 New York, mental health services were provided to deal with disaster-related
distress. There was an aggressive media campaign promoting the availability of free counseling, public
education, and referral services (Frank, et al., 2006). By advertising through electronic media, mental
health services were able to overcome the barriers of stigma and lack of information (Frank, et al., 2006)
. It was found that electronic media may be effective in encouraging help-seeking behaviour (Frank, et al.,
2006). When incorporating electronic media into public mental health campaigns, individuals were more
apt to seek treatment.
Success has also been documented among suicide prevention centers in the United States
(Estrine, Hettenbach, Arthur, & Messina, 2011). Within the United States, a few suicide prevention
centers are providing crisis services online (Estrine, Hettenbach, Arthur, & Messina, 2011). Online
services have been provided through the use of chat room communication. There has been a great deal of
criticism regarding effectiveness, but these centers have been very successful. These online crisis centers
have reported that individuals who reach out are able to openly express themselves in online venues
(Estrine, Hettenbach, Arthur, & Messina, 2011). This is likely a result of the online dis-inhibition effect,
which refers to the tendency of people to open up more and say more about themselves online than in
telephone or face to face interactions (Estrine, Hettenbach, Arthur, & Messina, 2011). The success of
online crisis intervention demonstrates the importance of online mental health services. If mental health
services were able to interact with individuals through social media, this would increase the availability
and mobility of mental health support.
Conclusion
In conclusion, our current mental health system presents clear treatment barriers. This literature
review discussed the growing use of social media, especially within the healthcare field. Overall, social
media can be used to help overcome treatment barriers. Diminishing treatment barriers can positively
affect an individual and how they relate to their community. Within the mental health field, social media
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 8
use can make a significant difference for patients. The following case studies demonstrate effective
mental health case management and intervention through social media. The names of the studied
individuals have been changed to maintain confidentiality.
Case Study 1: Joe
History
Joe is a homeless male, approximately 50 years old. He is schizophrenic and exhibits symptoms
of severe paranoia. He also presents with persecutory delusions. Consequently, Joe exhibits very reclusive
behaviour and is mistrustful of others. This makes it very difficult to establish a clinical relationship. Joe
does not take any prescribed medication. Rather, he attempts to self-medicate with the use of marijuana.
However, the use of marijuana seems to intensify his delusions. In rare circumstances, he exhibits a
potential for violence.
Interventions
He presented himself to Toronto Police Headquarters on June 26, 2010. Upon his arrival, Joe
exhibited aggressive behaviour. More specifically, he was yelling loudly and threatening police officers.
Due to the G-20 summit taking place in Toronto at this time, Joe’s outburst was occurring in the midst of
a heavy police presence. In order to prevent further conflict, Cst. Scott Mills calmly approached Joe and
offered him something to eat. Through this, Mills was able to quietly remove him from the situation.
After this event, Mills continued to meet regularly with Joe and a trusting relationship was
formed. From this point, Mills contacted his colleague Anne Marie Batten. Batten was a crisis outreach
nurse who was able to provide Joe with additional support. In order to establish a clinical relationship, it
was important for Batten to meet with Joe independently. However, Mills and Batten case managed Joe
collaboratively.
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 9
Collaborative case management was achieved through the use of social media. For the most part,
communication regarding Joe occurred through the use of Twitter. In order to communicate more
effectively, the hashtag #Homeless Joe was created. This alias was selected by Joe himself.
From following the hastag #HomelessJoe, Joe was provided with a lot of unanticipated
community support. Many individuals on twitter began following #HomelessJoe. #HomelessJoe was
followed by journalists, police officers, and many other caring community members. As a result,
#HomelessJoe could be used for both communication and intervention purposes.
For instance, in spring 2012, both Mills and Batten were unable to locate Joe. In response
to Batten’s concerns, she tweeted that she was unable to locate #HomelessJoe. As a result, several
members of the public began to search for Joe. Through social networking, Joe was eventually located
by a concerned community member. Once Joe was located, it was clear that he required hospitalization.
Thus, he was admitted to a Toronto treatment facility. For this admission, he was both accompanied and
supported by Batten.
Results
Due to Joe’s paranoid and persecutory symptoms, he would be labeled “difficult to serve” within
the traditional health care system. However, Batten and Mills were able to establish a clinical relationship
with Joe. This relationship was achieved by establishing a level of trust. Such a level of trust is difficult to
establish with a client of this nature. Through the use of Twitter, Joe received a level of support that is
unattainable within our traditional healthcare system.
As a result of his relationship with Mills and Batten, Joe became more receptive and trusting
within the community. Joe was able to engage with various community supports. For example, Joe was
able to secure both housing and disability insurance. Prior to the use of #HomelessJoe, this outcome
would not have been established.
Benefit of Social Media Engagement
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 10
Social media was used to increase awareness, maintain community safety, and to enhance Joe’s
quality of life. With regards to awareness, #HomelessJoe was the subject of news articles highlighting
gaps in the current mental health system. #HomelessJoe encouraged discussion regarding unconventional
approaches to mental health management. Through Twitter, Batten and Mills continue to advocate for
changes in the mental health system.
Also, in Joe’s case, the use of social media had a direct impact upon community safety. Through
the use of #HomelessJoe, Batten and Mills were able to maintain direct contact with Joe. This allowed
for a level of monitoring and intervention that cannot be provided by our conventional health system.
Through social media contact, Joe’s potential for violence was reduced. Through #HomelessJoe, Joe’s
behaviour was monitored. If needed, hostility diffusion and crisis support was administered. Batten and
Mills were able to use a proactive and preventative approach, which counteracted Joe’s violent outbursts.
Through the use of Twitter, Batten and Mills were able to engage with Joe and earn his trust.
Ultimately, this led to an increase in Joe’s quality of life. Through frequent contact and support, Joe was
connected to appropriate resources and housing was obtained. Overall, there is a direct link between
housing and health. Once Joe’s housing was secured, his health showed overall improvement. He
demonstrated improvement in the following areas: nutrition, personal hygiene, and sleeping patterns.
However, it is important to note that Joe remained un-medicated. Since Joe refused medication, he still
required monitoring and support. Currently, Batten and Mills continue to monitor Joe.
Case Study 2: Aaron
History
Aaron is male, approximately 20 years old. He has been diagnosed with bipolar disorder,
depression, and social anxiety. Aaron is prone to suicidal ideation. He lives independently in his own
apartment. An Assertive Community Treatment Team (ACTT) meets with Aaron and provides support.
On occasion, Aaron has required support from the Mobile Crisis Intervention Team (MCIT). MCIT is a
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 11
team comprised of both a police officer and a nurse.
Interventions
In February 2013, Cst. Scott Mills was contacted by a person who has required online support in
the past. This individual was concerned for Aaron’s safety. Aaron had been posting suicidal thoughts on
his Facebook account. This prompted the concerned third party to seek assistance on Aaron’s behalf. In
order to provide Aaron with support, Mills contacted his colleague Anne Marie Batten.
Anne Marie Batten reached out to Aaron on Facebook. She sent him a friend request and he
promptly accepted. She then initiated communication via private messaging. Batten was able to engage
Aaron in conversation, establish trust, and complete a risk assessment. After lengthy communication, it
was determined that Aaron was not an immediate safety risk. Overall, Batten was able to diffuse and de-
escalate Aaron through Facebook messaging.
Results
Aaron was co-operative and appreciative of Batten’s support. He did not require hospital
admission or police intervention. Currently, he maintains Facebook contact with Anne Marie Batten. In
addition, his community team provides ongoing support.
Benefit of Social Media Engagement
Through the use of social media, Aaron was able to receive support in a timely manner. Once
Aaron began posting suicidal thoughts on Facebook, he received assistance quickly. By responding to his
Facebook posts, Aaron’s safety was ensured. Batten and Mills were able to prevent Aaron’s symptoms
from worsening. Due to social media interventions, a police response was not required. In addition,
transfer to hospital was not required. Aaron was able to receive the necessary support before his condition
worsened, which prevented a negative outcome.
Case Study 3: Nancy
History
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 12
Nancy is a female in her late-twenties. She has a history of anxiety, depression, and self-harm.
Nancy experiences frequent episodes of anxiety and difficulty coping. She lives in supportive housing.
However, her housing support is not sufficient. Since her needs are not met, she often seeks support
through social media. Nancy frequently tweets police officers. Using twitter, she often threatens self-
harm, which results in a police response.
Interventions
Due to the nature of her tweets, Cst. Scott Mills became involved with Nancy. Mills engaged
with Nancy through social media. Through the use of Twitter, Mills was able to earn Nancy’s trust.
Through online support, Mills encouraged Nancy to volunteer at community policing events.
Volunteering at events became a source of empowerment for Nancy.
Results
Once Mills established trust with Nancy, she was able to positively engage with other police
officers. She was also able to positively engage with Anne Marie Batten. Overall, Nancy’s quality of life
has significantly improved. She is less depressed and more trusting of others. Nancy is more confident
and shows an increased sense of self. When interacting with others, Nancy is much more comfortable in
social situations. As a result, she is engaging in less self-harm. To date, Nancy continues to be monitored
through social media.
Benefit of Social Media Engagement
Nancy has expressed that social media has enhanced her quality of life. When Nancy is
struggling, she is able to reach out through social media. Through Twitter, she receives assistance in a
timely manner. Overall, the use of social media provides Nancy with support and comfort. As mentioned
previously, Nancy is engaging in less self-harm. Since Batten and Mills have provided social media
support, Nancy has not required any hospital visits.
Case Study 4: Julie
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 13
History
Julie is a female in her mid-twenties. She has been diagnosed with autism. In addition, she
displays symptoms of borderline personality disorder. Julie is very demanding and attention-seeking. She
has court-ordered case management support. In May 2011, Julie was communicating ideas about suicide
through Twitter. It was believed that Julie was a risk to herself.
Interventions
In response to her suicide ideation, Mills initially established communication through Twitter.
Once contact was established, communication extended to Facebook and Twitter. He was able to create a
trusting relationship. Although Mills maintained contact with Julie through social media, her behaviour
continued to escalate. Julie began sending hostile messages to various police officers. Her behaviour was
very disruptive.
In March 2012, Julie’s tweets required further intervention. Julie was tweeting slanderous
information about various police officers. It is believed that this was a ploy for attention. In response to
her behaviour, Mills consulted Anne Marie Batten. Anne Marie began to engage with Julie via social
media, providing online support. Julie has a heightened aggression response and frequently lashes out.
Because of this, Batten had to apply various diffusion techniques. Overall, Julie’s behaviour involved
frequent monitoring and diffusion.
It is relevant to note that while Julie was communicating with Batten and Mills, she continued to
reach out to other community members through Twitter. Julie continued to communicate her suicide
ideation and occasionally threatened self-harm. Through this, Julie had effectively created an extensive
community of online support. As a result, Julie’s online behaviour was difficult to manage.
Through communication with Julie, Batten and Mills were able to obtain consent to speak with
Julie’s case manager. Julie’s case manager informed Batten that Julie had not been attending
appointments or programs. Julie had told her case manager that she was receiving mental health support
in another city. However, it was discovered that this was false. In reality, Julie had been relying on her
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 14
social media contacts to provide mental health support. This was problematic because Julie had been
court-ordered to receive mental health treatment.
Batten, Mills, and Julie’s case manager continued to communicate. In order to effectively treat
Julie, Julie’s contact with her online community needed to be diminished. Through collaboration with
Julie’s case manager, some of Julie’s Twitter and Facebook contacts were messaged. Whilst maintaining
confidentiality, they asked some of Julie’s contacts to lessen their communication with her. Julie was
instructed to resume her court-mandated mental health treatment.
Results
To date, Julie continues to see her case manager. In order to ensure that Julie receives proper
treatment, her social media use is restricted.
Benefit of Social Media Engagement
Julie’s case has identified a specific gap in mental health case management. Use of social media
is often overlooked during treatment. To date, patient’s social media activities are not monitored by their
mental health workers. In Julie’s case, her mental health worker recognized the importance of online
support. Currently, Julie’s mental health case manager is advocating for the use of social media within
social service agencies. Many agencies discourage social media use, often blocking popular sites. This
hinders relationship-building and communication. It is also a barrier to treatment.
Case Study 5: Susan
History
Susan is a female in her thirties. She has been diagnosed with PTSD and depression. She
frequently expresses suicide ideation. In addition, she struggles with substance abuse. More specifically,
she struggles with her use of alcohol and marijuana. She has been prescribed anti-depressants. Susan uses
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 15
her medication sporadically, which makes her substance abuse very problematic. When mixing alcohol
and anti-depressants, she often experiences adverse effects. Because of her suicidality, she has required
police escorts into mental health facilities. As a result, she’s very hostile towards police officers and often
lashes out towards them. Due to her heightened aggression response, she receives court-mandated mental
health support. Susan lives independently and works full-time.
Susan often communicates her suicidal thoughts via Twitter. On several occasions, she has
tweeted at the Toronto Police’s corporate Twitter account. These tweets expressed suicide ideation and
Susan was considered a safety risk. On three occasions, the Toronto Police Communications Department
contacted Twitter and had Twitter trace her IP address. This is a very labour intensive process. However,
such labour was necessary because Susan’s behaviour was considered hazardous. In all three cases, Susan
was found and effectively de-escalated. However, since Susan required substantial police resources, Cst.
Scott Mills collaborated with the Communications Department to provide assistance.
Interventions
Cst. Scott Mills established contact with Susan using Twitter. Mills engaged with Susan and
was able to build a relationship with her through social media. Mills encouraged Susan to volunteer
at community policing events. Often, community policing events have Twitter and Facebook pages.
Through a community policing event’s Twitter page, Mills referred Susan to Anne Marie Batten. Batten
communicated with Susan via social media and established a trusting relationship. While communicating,
Susan expressed anxiety regarding an upcoming court appearance. Because Susan was anxious, Batten
provided online court support through direct messaging.
Batten has been able to intervene with Susan on a regular basis. Due to Susan’s heightened
aggression response, she has required frequent diffusion. Batten has employed various diffusion
techniques through Twitter. During one episode where there was an acute safety risk, Batten required
police assistance. Police intervention was required to ensure Susan’s safety. In this case, Batten remained
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 16
online with Susan while police transported her back to her apartment. Since Susan had been effectively
de-escalated, medical intervention was not required.
To date, Batten maintains contact with Susan through social media. Batten and Susan
communicate on a daily basis. Through Twitter, Batten has been able to provide Susan with support
through her court ordered treatment.
Results
As mentioned previously, Anne Marie Batten was able to provide court support through social
media. In order to receive support, Susan used a smartphone to communicate with Batten. While Susan
was attending her court hearing, she was able to communicate with Batten through social media. Batten
was able to diffuse Susan through Twitter, which prevented Susan from lashing out. Batten was able to
effectively manage Susan’s anxiety and hostility through online court support. This allowed Susan to
behave in a calm and controlled manner.
Susan receives court-mandated mental health treatment. In order to ensure Susan’s mental health
treatment is not compromised, Batten maintains superficial contact with Susan. Through Twitter, Batten
helps Susan to manage her emotional outbursts. Overall, Susan lacks social supports. By providing Susan
with online support, Batten and Mills have been able to enhance her quality of life.
Susan has expressed that she feels more supported. She also demonstrates more control over
her emotions. Since Batten and Mills have intervened, Susan has experienced less depressive episodes
and rarely lashes out. It is also important to note that, after Batten and Mills intervened, Susan began
using her medication regularly. She regularly uses medication because of her court ordered treatment.
In addition, Susan now communicates with a nurse regularly. Although Susan consults with a nurse, she
still maintains regular contact with Batten and Mills. By providing online support, Batten and Mills have
supplemented Susan’s treatment.
Benefit of Social Media Engagement
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 17
Generally speaking, Susan requires rapid intervention because of chronic crisis. Because of
her chronic crisis, Susan’s PTSD symptoms rapidly surface. Mills and Batten have been able meet
Susan’s needs through social media. Using Twitter, Mills and Batten can engage in short but rapid
communication. In addition, Susan has a very busy schedule and attends multiple appointments. Because
she has access to mobile internet, she is able to communicate with Mills and Batten through social media.
By using mobile internet, Susan can manage around her busy schedule.
Case Study 6: Laura
History
Laura is a female in her mid-20s. As a child, Laura was diagnosed with ADD and exhibited
behavioural problems in school. She also suffers from panic attacks and depression. Behaviourally, Laura
exhibits impulse control issues and a lack of control over her emotions. Laura is very sensitive to power
dynamics and will shut down or lash out if she feels that she is not in control. She lives independently and
is attending a post-secondary institution. Outside of this post-secondary institution, Laura has no
community supports. Laura also has a lack of familial support; she has no contact with her immediate
family members.
She has a heightened aggression response and frequently lashes out at police officers. In addition,
she threatens self-harm. Laura has a history of having police involvement for her behavioural problems.
On several occasions, Laura has made slanderous statements on the Toronto Police Service’s Facebook
page about specific police officers. More specifically, she has accused certain officers of encouraging her
suicide ideations. In response to Laura’s statements, the Issues Manager of the Toronto Police Department
contacted Batten. Batten was asked to engage with Laura and to provide assistance.
Interventions
Batten sent Laura a friend request on Facebook. In addition, Batten sent Laura a private message
on Facebook and introduced herself. Initially, Laura was very irate and thought that Batten was a police
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 18
officer. Through private messaging, Batten explained that she is a third party that helps the police with
individuals who are struggling and need support. Once Batten explained that she was a civilian, and not
an employee of the Toronto police, Laura became less hostile.
Batten was able to engage with Laura through private Facebook chatting. When chatting with
Batten, Laura openly discussed her past and her lack of social supports. Laura expressed a desire for
friendship and meaningful social connections. Overall, she expressed a need to be understood and
supported. Through Facebook chat, Batten was able to fulfill Laura’s need for social connection and
establish trust.
Results
Batten used Solution Focused Therapy techniques to connect with Laura. Rather than focusing
on the problems that required an individual to seek help, Solution Focused Therapy helps an individual
select outcomes and goals that they want to achieve. When Laura focuses on her past, she lashes out. By
encouraging Laura to focus her energy in a positive and constructive way, Batten was able to help Laura
regain control of her emotions.
Since Batten has intervened, Laura has been able to create a busy schedule for herself. Laura has
centered her efforts towards school work and other positive aspects of her life. Since Batten’s
involvement, Laura has not made any slanderous posts on the Toronto Police Service’s Facebook page.
Batten maintains contact with Laura, providing reassurance and empowerment. Batten also maintains
contact with the Toronto Police Issues Manager, informing them of Laura’s progress, status, and
behaviour.
Benefit of Social Media Engagement
Social media engagement was able to satisfy Laura’s need for meaningful social contacts. When
communicating with social media, there is no formality and no clinical environment. As a result, Laura
was more comfortable engaging with Batten. Batten was able to provide a non-threatening environment,
free of power dynamics and inequalities. As mentioned previously, Laura will lash out or shut down if
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 19
she is not in control. Because she is so sensitive to power dynamics, social media is an ideal form of
communication. Also, Laura was able to contact Batten on her own terms. If Laura wanted to
communicate, she had the power to send a message and receive a response.
Case Study 7: John
History
John is male and approximately 35 years old. He exhibits symptoms of anxiety and depression.
He lives independently and works full-time. Outside of work, John has no community supports. In
2012, John was arrested by the Toronto Police and charged with a minor offense. He had a very
negative experience with a Toronto Police officer. John was subjected to verbal abuse, characterized by
homophobic and derogatory comments. John was very upset by these remarks and turned to social media
for support. John began lashing out on Twitter. He was posting offensive and derogatory remarks about
the Toronto Police Service.
Interventions
Through the Toronto Police Twitter page, Cst. Scott Mills became aware of John’s comments.
Mills contacted John on Twitter and began to engage with him. Once Mills established contact with
John through the Toronto Police Service account, Mills decided to use his own account to relationship-
build. Thus, Mills began to interact with John using his individual police Twitter account. Mills was able
to build a trusting-relationship with John. Mills encouraged John to attend community policing events,
where John could interact with police officers in a comfortable environment. At a community policing
event, Mills introduced John to Anne Marie Batten. Batten began engaging with John on Twitter. John
maintained social media contact with Mills and Batten, as well as several police officers that attend
community events.
Results
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 20
John was able to establish meaningful connections through social media. By forming
relationships with Toronto police officers, John was able to positively engage with the Toronto Police
Service. As a result, John became more trusting and stopped posting derogatory statements on Twitter.
Through Mills’ encouragement, John participated in an anti-bullying presentation. This was a source of
empowerment, as John was able to speak openly about his negative experience.
Benefit of Social Media Engagement
Mills was able to establish contact through social media. As a police officer, it would have been
difficult for Mills to interact with him face-to-face. John’s negative experience with the Toronto Police
resulted in significant trust issues. Twitter provided a non-threatening environment, where John could
speak openly about his experience.
References
Ackerson, L. K., & Viswanath, K. (2009). The Social Context of Interpersonal Communication and Health.
Journal of Health Communication, 14, 5-17.Bender, J. L., Wiljer, D., To, M. J., Bedard, P. L.,
Chung, P., Jewette, M. A., . . . Gospodarowicz, M. (2012). Testicular Cancer Survivors'
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 21
Supportive Care Needs and Use of Online Support: A Cross-Sectional Survey . Supportive Care
in Cancer, 20, 2737–2746.Chen, G. M. (2011). Tweet This: A Uses and Gratifications
Perspective on How Active Twitter Use Gratifies a Need to Connect with Others. Computers in
Human Behaviour, 27, 755-762.Cleary, J. F. (2011). Jumping into the World of Social Media
with Palliative Medicine. Palliative Medicine, 25 (6), 611-612.Della, L. J., Eroglu, D., Bernhardt,
J. M., Edgerton, E., & Nall, J. (2008). Looking to the Future of New Media in Health Marketing:
Deriving Propositions Based on Traditional Theories. Health Marketing Quarterly, 25 (1-2), 147-
174.Estrine, S., Hettenbach, R., Arthur, H., & Messina, M. (2011). Service Delivery for
Vulnerable Populations: New Directions in Behavioral Health . New York : Springer Publishing
Company.Frank, R. G., Pindyck, T., Donahue, S. A., Pease, E. A., Foster, M. J., Felton, C. J., &
Essock, S. M. (2006). Impact of a Media Campaign for Disaster Mental Health Counselling in
Post-September 11 New York. Psychiatric Services, 57 (9), 1304-1309.Ipsos Reid. (2012). The
Ipsos Canadian Interactive Reid Report. Ipsos Reid.Johnson, P. R., & Yang, S.-U. (2009). Uses
and Gratifications of Twitter: An Examination of User Motives and Satisfaction of Twitter Use.
New York: S. I. Newhouse School of Public Communications, Syracuse University.Kontos, E.
Z., Emmons, K. M., Puleo, E., & Viswanath, K. (2010). Communication Inequalities and Public
Health Implications of Adult Social Networking Use in the United States. Journal of Health
Communication, 15, 216-235.Mental Health Commission of Canada. (2012). Changing
Directions, Changing Lives: The Mental Health Strategy for Canada. Calgary, Alberta.Sareen, J.,
Jagdeo, A., Cox, B. J., Clara, I., ten Have, M., Belik, S.-L., . . . Stein, M. B. (2007). Percieved
Barriers to Mental Health Service Utilization in the United States, Ontario, and the Netherlands.
Psychiatric Services, 58 (3), 357-364.Steele, L. S., Glazier, R., & Lin, E. (2006). Inequity in
Mental Health Care Under Canadian Universal Health Coverage. Psychiatric Services, 57 (3),
317-324.Steele, L., Dewa, C., & Lee, K. (2007). Socioeconomic Status and Self-Reported
Barriers to Mental Health Service Use. Canadian Journal of Psychiatry, 201-206.Wang, J. (2006).
SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 22
Perceived Barriers to Mental Health Service Use among Individuals with Mental Disorders in the
Canadian General Population. Medical Care, 44 (2), 192-195.

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Case Studies & Literature Review * Real Time Crisis Centre Hub #RTCH

  • 1. Running Head: SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 1 Social Media and Mental Health Intervention: A Collection of Case Studies Emma Batten, B.A. (Hons) In consultation with Constable Scott Mills and Anne Marie Batten RN Success and Safety Relationships and Technology Centers (SSRTC) April 19, 2013
  • 2. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 2 Literature Review Barriers to Treatment In recent years, the Canadian mental health system’s effectiveness has been called into question. Numerous studies have identified treatment barriers. Such barriers unintentionally deny a patient from accessing treatment. The Mental Health Commission of Canada has stated that, “Only one in three people who experience a mental health problem or illness- and as few as one in four children or youth- report that they have sought and received services and treatment” (Mental Health Commission of Canada, 2012, p. 12). This is atypical of other health conditions and suggests an inadequacy in current mental health services. A Canadian study conducted in 2006 by Wang provides some useful statistics. Of the 4094 participants in this study, 21.6% reported that they required assistance for mental health or substance abuse issues and did not receive it (Wang, 2006). These participants were also asked to provide reasons for their lack of treatment. Of this 21.6%, 794 participants reported various treatment barriers (Wang, 2006). However, the treatment barriers commonly reported were related to acceptability rather than accessibility (Wang, 2006). In other words, individuals chose to avoid treatment because of perceived social stigma. With regards to treatment barriers, there are two distinct categories. These categories are referred to as acceptability barriers and accessibility barriers. Acceptability barriers refer to issues of stigma and social acceptance. On the other hand, accessibility barriers refer to the availability and accessible nature of services. In the case of Wang’s study, participants reported issues of social acceptance as their perceived treatment barriers. Thus, availability of mental health services was not perceived as an issue. The Mental Health Commission of Canada has supported this idea. According to their report, stigma and the fear of being labeled prevent many individuals from seeking mental health services (Mental Health Commission of Canada, 2012). In addition, some people are unaware that they have a mental health problem, which can result from either a lack of knowledge or the symptoms of the mental
  • 3. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 3 disorder itself (Mental Health Commission of Canada, 2012). Interestingly, other Canadian studies have identified lack of knowledge as a barrier to treatment. A Canadian study in 2007 found that low-income individuals who had not completed high school were the most likely group to report acceptability barriers to mental health care (Steele, Dewa, & Lee, 2007). With regards to treatment barriers, low education levels are strongly correlated with perceptions of stigma. This is consistent with the idea that a lack of knowledge, or education, can serve as a treatment barrier. An individual may be unaware that they require treatment. In a study based on Ontario’s health care system, patients reported financial barriers to treatment (Sareen, et al., 2007). This is consistent with another Canadian study conducted in 2006 (Steele, Glazier, & Lin, 2006). High-income respondents are more likely to receive mental health services (Steele, Glazier, & Lin, 2006). Since Canada’s health care system is universally funded, it is possible that individuals of lower socioeconomic status are not receiving treatment due to a lack of education. This supports the notion that education and mental health treatment are linked. Within Canada, there is a need for increased outreach to low-income individuals (Sareen, et al., 2007). This presents an interesting challenge for Canada’s mental health system. The prevailing issue is not availability of resources. Rather, there appears to be a fundamental disconnect between patients and available services. To date, there are a significant percentage of mentally afflicted patients who are not receiving treatment. This has serious implications, since an untreated mental illness affects an individual’s quality of life. Also, on a macro level, untreated mental illness can have a negative effect on the health and productivity of a community (Sareen, et al., 2007). Social Media Use Before discussing the relationship between social media and mental health services, it is important to note the growing use of social media in general. In the last decade, social media has become increasingly popular. According to Ipsos’ most recent report, more than one-half (62%) of all Canadians have visited or browsed a social networking site (Ipsos Reid, 2012). This is higher than ever before. This
  • 4. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 4 increase in social networking may be due to an increase in mobile internet access. Currently, 86% of Canadians have access to the Internet (Ipsos Reid, 2012). There has not been an increase in Internet access over the past few years (Ipsos Reid, 2012). However, 37% of Canadians now have mobile Internet access (Ipsos Reid, 2012). This is a dramatic increase from Ipsos’ 2001 statistics, where only 5% of participants possessed mobile Internet access (Ipsos Reid, 2012). Overall, the increase in availability of mobile internet access may be responsible for the increase in social network use. Of the Canadians who have visited a social networking site, approximately half report visiting a site on a daily basis (Ipsos Reid, 2012). This is an increase compared to recent years, and suggests that participant’s reliance on social networking has increased. In fact, 41% of Canadians felt that they communicated with people online more than offline (Ipsos Reid, 2012). Thus, it would appear that social media has become a tool for individuals to communicate and relationship-build. According to Ipsos, the most popular social networking sites appear to be Facebook, Twitter, Linked-In (Ipsos Reid, 2012). With regards to Twitter, research has shown that individuals are using the site to share information and meet people (Johnson & Yang, 2009). A study conducted by Chen in 2011 seems to expand on this notion. Chen found that, through Twitter, individuals can gratify the basic human need to connect with other people (Chen, 2011). Twitter appears to be a medium that people actively seek out in order to connect with others (Chen, 2011). By facilitating interpersonal communication, social networking sites can improve an individual’s psychological well-being. There is evidence to support the idea that social networking can have psychological benefits. Using social media, individuals can express their feelings and share ideas. Social networking can also be used to relationship-build and connect with other individuals or groups. Communication plays a vital role in integrating people into their communities (Kontos, Emmons, Puleo, & Viswanath, 2010). Such integration can be achieved by helping to build support, maintain ties, and promote trust (Ackerson &
  • 5. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 5 Viswanath, 2009). Through social networking sites, individuals can reach out and establish meaningful social connections. Medical Uses for Social Media Because social media is used for relationship-building and information-sharing, many health programs have begun to connect with individuals through social networking sites. Social networking offers the potential for mass collaboration, which is useful from a health standpoint. Studies have shown that there is an absence of inequalities with regards to social network use. With regards to Internet access, there are significant disparities among racial, ethnic and social groups. Generally speaking, there are sociodemographic inequalities when it comes to Internet access. However, it has been shown that, once Internet access is gained, there is consistent use of social networking sites regardless of any sociodemographic characteristics (Kontos, Emmons, Puleo, & Viswanath, 2010). Thus, there is an absence of inequalities with regards to social networking. This suggests that social networking sites might be an effective tool for sharing health information. For example, there has been success with sharing public health interventions on social media sites (Kontos, Emmons, Puleo, & Viswanath, 2010). Through social media, health care services can communicate with many different groups of people. However, many workplaces do not allow their employees to engage in social media. There has been research to demonstrate that social media can enhance a workplace’s performance, specifically within the health care field. A good example of this is the Mayo Clinic in the United States. The Mayo clinic has embraced social media and has become very popular online. The Mayo Clinic has the most popular medical provider YouTube channel and nearly 200 000 Twitter followers (Cleary, 2011). The Mayo Clinic has been able to use social networking to share health information and spread awareness. In the past decade, there has been an increase in online health information. Recently, this digital health information has become more mobile (Della, Eroglu, Bernhardt, Edgerton, & Nall, 2008). A good example of this is the Apple Store, also referred to as iTunes, which sells digital media online. iTunes
  • 6. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 6 provides free podcast sessions from numerous health information sources (Della, Eroglu, Bernhardt, Edgerton, & Nall, 2008). This allows individuals to download health information right to their mobile devices. Many large health institutions are also offering podcasts and RSS feeds directly from their respective websites (Della, Eroglu, Bernhardt, Edgerton, & Nall, 2008). There has been a dramatic change in the way that individuals receive and share health information. As a society, reliance on digital information is rapidly increasing. Many medical institutions have responded by offering online health care information. Social Media and Mental Health Within the mental health field, it is believed that social media use can make a significant difference. As discussed previously, there are significant treatment barriers within the mental health system. Many individuals do not receive treatment for their symptoms due to acceptability barriers. However, social media allows for individuals to interact with mental health supports in a comfortable environment. As previously stated, 41% of Canadians currently communicate with individuals online more frequently than offline (Ipsos Reid, 2012). For individuals who prefer online communication, social media could serve as an effective tool to provide mental health counseling. Also, the portability of social media allows for rapid, unencumbered communication. To date, there is not a lot of literature examining the effectiveness of mental health case management through social media. However, a Canadian study in 2012 has demonstrated that there is a desire for online mental health counseling services (Bender, et al., 2012). This study involved testicular cancer survivors, who were recruited through the Princess Margaret Hospital. Of the participants who used social media, more than half (60%) expressed a desire to engage in online supports (Bender, et al., 2012). Furthermore, 26% of the social media using participants admitted to using online communities for support related to testicular cancer (Bender, et al., 2012). Thus, individuals were using the Internet to supplement their treatment process. By reaching out through social networking, testicular cancer survivors were able to satisfy psychosocial needs.
  • 7. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 7 Social media can also serve as an effective tool to communicate public mental health information. For example, in post-911 New York, mental health services were provided to deal with disaster-related distress. There was an aggressive media campaign promoting the availability of free counseling, public education, and referral services (Frank, et al., 2006). By advertising through electronic media, mental health services were able to overcome the barriers of stigma and lack of information (Frank, et al., 2006) . It was found that electronic media may be effective in encouraging help-seeking behaviour (Frank, et al., 2006). When incorporating electronic media into public mental health campaigns, individuals were more apt to seek treatment. Success has also been documented among suicide prevention centers in the United States (Estrine, Hettenbach, Arthur, & Messina, 2011). Within the United States, a few suicide prevention centers are providing crisis services online (Estrine, Hettenbach, Arthur, & Messina, 2011). Online services have been provided through the use of chat room communication. There has been a great deal of criticism regarding effectiveness, but these centers have been very successful. These online crisis centers have reported that individuals who reach out are able to openly express themselves in online venues (Estrine, Hettenbach, Arthur, & Messina, 2011). This is likely a result of the online dis-inhibition effect, which refers to the tendency of people to open up more and say more about themselves online than in telephone or face to face interactions (Estrine, Hettenbach, Arthur, & Messina, 2011). The success of online crisis intervention demonstrates the importance of online mental health services. If mental health services were able to interact with individuals through social media, this would increase the availability and mobility of mental health support. Conclusion In conclusion, our current mental health system presents clear treatment barriers. This literature review discussed the growing use of social media, especially within the healthcare field. Overall, social media can be used to help overcome treatment barriers. Diminishing treatment barriers can positively affect an individual and how they relate to their community. Within the mental health field, social media
  • 8. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 8 use can make a significant difference for patients. The following case studies demonstrate effective mental health case management and intervention through social media. The names of the studied individuals have been changed to maintain confidentiality. Case Study 1: Joe History Joe is a homeless male, approximately 50 years old. He is schizophrenic and exhibits symptoms of severe paranoia. He also presents with persecutory delusions. Consequently, Joe exhibits very reclusive behaviour and is mistrustful of others. This makes it very difficult to establish a clinical relationship. Joe does not take any prescribed medication. Rather, he attempts to self-medicate with the use of marijuana. However, the use of marijuana seems to intensify his delusions. In rare circumstances, he exhibits a potential for violence. Interventions He presented himself to Toronto Police Headquarters on June 26, 2010. Upon his arrival, Joe exhibited aggressive behaviour. More specifically, he was yelling loudly and threatening police officers. Due to the G-20 summit taking place in Toronto at this time, Joe’s outburst was occurring in the midst of a heavy police presence. In order to prevent further conflict, Cst. Scott Mills calmly approached Joe and offered him something to eat. Through this, Mills was able to quietly remove him from the situation. After this event, Mills continued to meet regularly with Joe and a trusting relationship was formed. From this point, Mills contacted his colleague Anne Marie Batten. Batten was a crisis outreach nurse who was able to provide Joe with additional support. In order to establish a clinical relationship, it was important for Batten to meet with Joe independently. However, Mills and Batten case managed Joe collaboratively.
  • 9. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 9 Collaborative case management was achieved through the use of social media. For the most part, communication regarding Joe occurred through the use of Twitter. In order to communicate more effectively, the hashtag #Homeless Joe was created. This alias was selected by Joe himself. From following the hastag #HomelessJoe, Joe was provided with a lot of unanticipated community support. Many individuals on twitter began following #HomelessJoe. #HomelessJoe was followed by journalists, police officers, and many other caring community members. As a result, #HomelessJoe could be used for both communication and intervention purposes. For instance, in spring 2012, both Mills and Batten were unable to locate Joe. In response to Batten’s concerns, she tweeted that she was unable to locate #HomelessJoe. As a result, several members of the public began to search for Joe. Through social networking, Joe was eventually located by a concerned community member. Once Joe was located, it was clear that he required hospitalization. Thus, he was admitted to a Toronto treatment facility. For this admission, he was both accompanied and supported by Batten. Results Due to Joe’s paranoid and persecutory symptoms, he would be labeled “difficult to serve” within the traditional health care system. However, Batten and Mills were able to establish a clinical relationship with Joe. This relationship was achieved by establishing a level of trust. Such a level of trust is difficult to establish with a client of this nature. Through the use of Twitter, Joe received a level of support that is unattainable within our traditional healthcare system. As a result of his relationship with Mills and Batten, Joe became more receptive and trusting within the community. Joe was able to engage with various community supports. For example, Joe was able to secure both housing and disability insurance. Prior to the use of #HomelessJoe, this outcome would not have been established. Benefit of Social Media Engagement
  • 10. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 10 Social media was used to increase awareness, maintain community safety, and to enhance Joe’s quality of life. With regards to awareness, #HomelessJoe was the subject of news articles highlighting gaps in the current mental health system. #HomelessJoe encouraged discussion regarding unconventional approaches to mental health management. Through Twitter, Batten and Mills continue to advocate for changes in the mental health system. Also, in Joe’s case, the use of social media had a direct impact upon community safety. Through the use of #HomelessJoe, Batten and Mills were able to maintain direct contact with Joe. This allowed for a level of monitoring and intervention that cannot be provided by our conventional health system. Through social media contact, Joe’s potential for violence was reduced. Through #HomelessJoe, Joe’s behaviour was monitored. If needed, hostility diffusion and crisis support was administered. Batten and Mills were able to use a proactive and preventative approach, which counteracted Joe’s violent outbursts. Through the use of Twitter, Batten and Mills were able to engage with Joe and earn his trust. Ultimately, this led to an increase in Joe’s quality of life. Through frequent contact and support, Joe was connected to appropriate resources and housing was obtained. Overall, there is a direct link between housing and health. Once Joe’s housing was secured, his health showed overall improvement. He demonstrated improvement in the following areas: nutrition, personal hygiene, and sleeping patterns. However, it is important to note that Joe remained un-medicated. Since Joe refused medication, he still required monitoring and support. Currently, Batten and Mills continue to monitor Joe. Case Study 2: Aaron History Aaron is male, approximately 20 years old. He has been diagnosed with bipolar disorder, depression, and social anxiety. Aaron is prone to suicidal ideation. He lives independently in his own apartment. An Assertive Community Treatment Team (ACTT) meets with Aaron and provides support. On occasion, Aaron has required support from the Mobile Crisis Intervention Team (MCIT). MCIT is a
  • 11. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 11 team comprised of both a police officer and a nurse. Interventions In February 2013, Cst. Scott Mills was contacted by a person who has required online support in the past. This individual was concerned for Aaron’s safety. Aaron had been posting suicidal thoughts on his Facebook account. This prompted the concerned third party to seek assistance on Aaron’s behalf. In order to provide Aaron with support, Mills contacted his colleague Anne Marie Batten. Anne Marie Batten reached out to Aaron on Facebook. She sent him a friend request and he promptly accepted. She then initiated communication via private messaging. Batten was able to engage Aaron in conversation, establish trust, and complete a risk assessment. After lengthy communication, it was determined that Aaron was not an immediate safety risk. Overall, Batten was able to diffuse and de- escalate Aaron through Facebook messaging. Results Aaron was co-operative and appreciative of Batten’s support. He did not require hospital admission or police intervention. Currently, he maintains Facebook contact with Anne Marie Batten. In addition, his community team provides ongoing support. Benefit of Social Media Engagement Through the use of social media, Aaron was able to receive support in a timely manner. Once Aaron began posting suicidal thoughts on Facebook, he received assistance quickly. By responding to his Facebook posts, Aaron’s safety was ensured. Batten and Mills were able to prevent Aaron’s symptoms from worsening. Due to social media interventions, a police response was not required. In addition, transfer to hospital was not required. Aaron was able to receive the necessary support before his condition worsened, which prevented a negative outcome. Case Study 3: Nancy History
  • 12. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 12 Nancy is a female in her late-twenties. She has a history of anxiety, depression, and self-harm. Nancy experiences frequent episodes of anxiety and difficulty coping. She lives in supportive housing. However, her housing support is not sufficient. Since her needs are not met, she often seeks support through social media. Nancy frequently tweets police officers. Using twitter, she often threatens self- harm, which results in a police response. Interventions Due to the nature of her tweets, Cst. Scott Mills became involved with Nancy. Mills engaged with Nancy through social media. Through the use of Twitter, Mills was able to earn Nancy’s trust. Through online support, Mills encouraged Nancy to volunteer at community policing events. Volunteering at events became a source of empowerment for Nancy. Results Once Mills established trust with Nancy, she was able to positively engage with other police officers. She was also able to positively engage with Anne Marie Batten. Overall, Nancy’s quality of life has significantly improved. She is less depressed and more trusting of others. Nancy is more confident and shows an increased sense of self. When interacting with others, Nancy is much more comfortable in social situations. As a result, she is engaging in less self-harm. To date, Nancy continues to be monitored through social media. Benefit of Social Media Engagement Nancy has expressed that social media has enhanced her quality of life. When Nancy is struggling, she is able to reach out through social media. Through Twitter, she receives assistance in a timely manner. Overall, the use of social media provides Nancy with support and comfort. As mentioned previously, Nancy is engaging in less self-harm. Since Batten and Mills have provided social media support, Nancy has not required any hospital visits. Case Study 4: Julie
  • 13. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 13 History Julie is a female in her mid-twenties. She has been diagnosed with autism. In addition, she displays symptoms of borderline personality disorder. Julie is very demanding and attention-seeking. She has court-ordered case management support. In May 2011, Julie was communicating ideas about suicide through Twitter. It was believed that Julie was a risk to herself. Interventions In response to her suicide ideation, Mills initially established communication through Twitter. Once contact was established, communication extended to Facebook and Twitter. He was able to create a trusting relationship. Although Mills maintained contact with Julie through social media, her behaviour continued to escalate. Julie began sending hostile messages to various police officers. Her behaviour was very disruptive. In March 2012, Julie’s tweets required further intervention. Julie was tweeting slanderous information about various police officers. It is believed that this was a ploy for attention. In response to her behaviour, Mills consulted Anne Marie Batten. Anne Marie began to engage with Julie via social media, providing online support. Julie has a heightened aggression response and frequently lashes out. Because of this, Batten had to apply various diffusion techniques. Overall, Julie’s behaviour involved frequent monitoring and diffusion. It is relevant to note that while Julie was communicating with Batten and Mills, she continued to reach out to other community members through Twitter. Julie continued to communicate her suicide ideation and occasionally threatened self-harm. Through this, Julie had effectively created an extensive community of online support. As a result, Julie’s online behaviour was difficult to manage. Through communication with Julie, Batten and Mills were able to obtain consent to speak with Julie’s case manager. Julie’s case manager informed Batten that Julie had not been attending appointments or programs. Julie had told her case manager that she was receiving mental health support in another city. However, it was discovered that this was false. In reality, Julie had been relying on her
  • 14. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 14 social media contacts to provide mental health support. This was problematic because Julie had been court-ordered to receive mental health treatment. Batten, Mills, and Julie’s case manager continued to communicate. In order to effectively treat Julie, Julie’s contact with her online community needed to be diminished. Through collaboration with Julie’s case manager, some of Julie’s Twitter and Facebook contacts were messaged. Whilst maintaining confidentiality, they asked some of Julie’s contacts to lessen their communication with her. Julie was instructed to resume her court-mandated mental health treatment. Results To date, Julie continues to see her case manager. In order to ensure that Julie receives proper treatment, her social media use is restricted. Benefit of Social Media Engagement Julie’s case has identified a specific gap in mental health case management. Use of social media is often overlooked during treatment. To date, patient’s social media activities are not monitored by their mental health workers. In Julie’s case, her mental health worker recognized the importance of online support. Currently, Julie’s mental health case manager is advocating for the use of social media within social service agencies. Many agencies discourage social media use, often blocking popular sites. This hinders relationship-building and communication. It is also a barrier to treatment. Case Study 5: Susan History Susan is a female in her thirties. She has been diagnosed with PTSD and depression. She frequently expresses suicide ideation. In addition, she struggles with substance abuse. More specifically, she struggles with her use of alcohol and marijuana. She has been prescribed anti-depressants. Susan uses
  • 15. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 15 her medication sporadically, which makes her substance abuse very problematic. When mixing alcohol and anti-depressants, she often experiences adverse effects. Because of her suicidality, she has required police escorts into mental health facilities. As a result, she’s very hostile towards police officers and often lashes out towards them. Due to her heightened aggression response, she receives court-mandated mental health support. Susan lives independently and works full-time. Susan often communicates her suicidal thoughts via Twitter. On several occasions, she has tweeted at the Toronto Police’s corporate Twitter account. These tweets expressed suicide ideation and Susan was considered a safety risk. On three occasions, the Toronto Police Communications Department contacted Twitter and had Twitter trace her IP address. This is a very labour intensive process. However, such labour was necessary because Susan’s behaviour was considered hazardous. In all three cases, Susan was found and effectively de-escalated. However, since Susan required substantial police resources, Cst. Scott Mills collaborated with the Communications Department to provide assistance. Interventions Cst. Scott Mills established contact with Susan using Twitter. Mills engaged with Susan and was able to build a relationship with her through social media. Mills encouraged Susan to volunteer at community policing events. Often, community policing events have Twitter and Facebook pages. Through a community policing event’s Twitter page, Mills referred Susan to Anne Marie Batten. Batten communicated with Susan via social media and established a trusting relationship. While communicating, Susan expressed anxiety regarding an upcoming court appearance. Because Susan was anxious, Batten provided online court support through direct messaging. Batten has been able to intervene with Susan on a regular basis. Due to Susan’s heightened aggression response, she has required frequent diffusion. Batten has employed various diffusion techniques through Twitter. During one episode where there was an acute safety risk, Batten required police assistance. Police intervention was required to ensure Susan’s safety. In this case, Batten remained
  • 16. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 16 online with Susan while police transported her back to her apartment. Since Susan had been effectively de-escalated, medical intervention was not required. To date, Batten maintains contact with Susan through social media. Batten and Susan communicate on a daily basis. Through Twitter, Batten has been able to provide Susan with support through her court ordered treatment. Results As mentioned previously, Anne Marie Batten was able to provide court support through social media. In order to receive support, Susan used a smartphone to communicate with Batten. While Susan was attending her court hearing, she was able to communicate with Batten through social media. Batten was able to diffuse Susan through Twitter, which prevented Susan from lashing out. Batten was able to effectively manage Susan’s anxiety and hostility through online court support. This allowed Susan to behave in a calm and controlled manner. Susan receives court-mandated mental health treatment. In order to ensure Susan’s mental health treatment is not compromised, Batten maintains superficial contact with Susan. Through Twitter, Batten helps Susan to manage her emotional outbursts. Overall, Susan lacks social supports. By providing Susan with online support, Batten and Mills have been able to enhance her quality of life. Susan has expressed that she feels more supported. She also demonstrates more control over her emotions. Since Batten and Mills have intervened, Susan has experienced less depressive episodes and rarely lashes out. It is also important to note that, after Batten and Mills intervened, Susan began using her medication regularly. She regularly uses medication because of her court ordered treatment. In addition, Susan now communicates with a nurse regularly. Although Susan consults with a nurse, she still maintains regular contact with Batten and Mills. By providing online support, Batten and Mills have supplemented Susan’s treatment. Benefit of Social Media Engagement
  • 17. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 17 Generally speaking, Susan requires rapid intervention because of chronic crisis. Because of her chronic crisis, Susan’s PTSD symptoms rapidly surface. Mills and Batten have been able meet Susan’s needs through social media. Using Twitter, Mills and Batten can engage in short but rapid communication. In addition, Susan has a very busy schedule and attends multiple appointments. Because she has access to mobile internet, she is able to communicate with Mills and Batten through social media. By using mobile internet, Susan can manage around her busy schedule. Case Study 6: Laura History Laura is a female in her mid-20s. As a child, Laura was diagnosed with ADD and exhibited behavioural problems in school. She also suffers from panic attacks and depression. Behaviourally, Laura exhibits impulse control issues and a lack of control over her emotions. Laura is very sensitive to power dynamics and will shut down or lash out if she feels that she is not in control. She lives independently and is attending a post-secondary institution. Outside of this post-secondary institution, Laura has no community supports. Laura also has a lack of familial support; she has no contact with her immediate family members. She has a heightened aggression response and frequently lashes out at police officers. In addition, she threatens self-harm. Laura has a history of having police involvement for her behavioural problems. On several occasions, Laura has made slanderous statements on the Toronto Police Service’s Facebook page about specific police officers. More specifically, she has accused certain officers of encouraging her suicide ideations. In response to Laura’s statements, the Issues Manager of the Toronto Police Department contacted Batten. Batten was asked to engage with Laura and to provide assistance. Interventions Batten sent Laura a friend request on Facebook. In addition, Batten sent Laura a private message on Facebook and introduced herself. Initially, Laura was very irate and thought that Batten was a police
  • 18. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 18 officer. Through private messaging, Batten explained that she is a third party that helps the police with individuals who are struggling and need support. Once Batten explained that she was a civilian, and not an employee of the Toronto police, Laura became less hostile. Batten was able to engage with Laura through private Facebook chatting. When chatting with Batten, Laura openly discussed her past and her lack of social supports. Laura expressed a desire for friendship and meaningful social connections. Overall, she expressed a need to be understood and supported. Through Facebook chat, Batten was able to fulfill Laura’s need for social connection and establish trust. Results Batten used Solution Focused Therapy techniques to connect with Laura. Rather than focusing on the problems that required an individual to seek help, Solution Focused Therapy helps an individual select outcomes and goals that they want to achieve. When Laura focuses on her past, she lashes out. By encouraging Laura to focus her energy in a positive and constructive way, Batten was able to help Laura regain control of her emotions. Since Batten has intervened, Laura has been able to create a busy schedule for herself. Laura has centered her efforts towards school work and other positive aspects of her life. Since Batten’s involvement, Laura has not made any slanderous posts on the Toronto Police Service’s Facebook page. Batten maintains contact with Laura, providing reassurance and empowerment. Batten also maintains contact with the Toronto Police Issues Manager, informing them of Laura’s progress, status, and behaviour. Benefit of Social Media Engagement Social media engagement was able to satisfy Laura’s need for meaningful social contacts. When communicating with social media, there is no formality and no clinical environment. As a result, Laura was more comfortable engaging with Batten. Batten was able to provide a non-threatening environment, free of power dynamics and inequalities. As mentioned previously, Laura will lash out or shut down if
  • 19. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 19 she is not in control. Because she is so sensitive to power dynamics, social media is an ideal form of communication. Also, Laura was able to contact Batten on her own terms. If Laura wanted to communicate, she had the power to send a message and receive a response. Case Study 7: John History John is male and approximately 35 years old. He exhibits symptoms of anxiety and depression. He lives independently and works full-time. Outside of work, John has no community supports. In 2012, John was arrested by the Toronto Police and charged with a minor offense. He had a very negative experience with a Toronto Police officer. John was subjected to verbal abuse, characterized by homophobic and derogatory comments. John was very upset by these remarks and turned to social media for support. John began lashing out on Twitter. He was posting offensive and derogatory remarks about the Toronto Police Service. Interventions Through the Toronto Police Twitter page, Cst. Scott Mills became aware of John’s comments. Mills contacted John on Twitter and began to engage with him. Once Mills established contact with John through the Toronto Police Service account, Mills decided to use his own account to relationship- build. Thus, Mills began to interact with John using his individual police Twitter account. Mills was able to build a trusting-relationship with John. Mills encouraged John to attend community policing events, where John could interact with police officers in a comfortable environment. At a community policing event, Mills introduced John to Anne Marie Batten. Batten began engaging with John on Twitter. John maintained social media contact with Mills and Batten, as well as several police officers that attend community events. Results
  • 20. SOCIAL MEDIA AND MENTAL HEALTH INTERVENTION 20 John was able to establish meaningful connections through social media. By forming relationships with Toronto police officers, John was able to positively engage with the Toronto Police Service. As a result, John became more trusting and stopped posting derogatory statements on Twitter. Through Mills’ encouragement, John participated in an anti-bullying presentation. This was a source of empowerment, as John was able to speak openly about his negative experience. Benefit of Social Media Engagement Mills was able to establish contact through social media. As a police officer, it would have been difficult for Mills to interact with him face-to-face. John’s negative experience with the Toronto Police resulted in significant trust issues. Twitter provided a non-threatening environment, where John could speak openly about his experience. References Ackerson, L. K., & Viswanath, K. (2009). The Social Context of Interpersonal Communication and Health. Journal of Health Communication, 14, 5-17.Bender, J. L., Wiljer, D., To, M. J., Bedard, P. L., Chung, P., Jewette, M. A., . . . Gospodarowicz, M. (2012). Testicular Cancer Survivors'
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