Creating a collaborative learning space
Participants come to an online space with expectations of relevance and how to post [25
]. Here, the MHPs, MHSUs, and researchers started off with assumptions about relevant information and appropriate behaviour, which can be seen in what participants chose to introduce as relevant, and how these contributed to posting expectations. Previously, anonymity had been shown to be important to MHPs [13
], who worried about professional implications of giving advice online. Anonymity was therefore central to this course design, and our aim had been to try and provide a non-hierarchical interactional space for MHPs and MHSUs. However, studies of online forums show that participants routinely demonstrate their status as members or experts [26
]. When joining this course, what information did people provide about themselves?
In the opening webcast, participants were welcomed with music (Vivaldi) and chat about the weather, until the official opening by Ray:
Extract 1: Course 2, First webcast
1. Ray1 so please do introduce yourselves
2. Manon ok.. well Hi.. I'm a mental health practitioner.. and I became involved in
3. mental health fifteen years ago after I experienced a bout of depression and had support
4. from the services back then.. so I'm happy to be thought of as both a service user and prac
5. Emily Hello! Welcome to the course. As you know I'm Emily and I'm the Ehealth
7. Ray all, say maybe something about your use of the Internet?
8. Sharpeye Hi there I'm Sharpeye but feeling peaky eyed today! A mental health practitioner
9. from Scotland. Use the Internet everyday and a couple of social networking sites.
10. Mole Im a MH user, i have previously used forums (although not much in the last 6
12. and was involved with the Sharp talk project. i am on the Internet alot though (facebook,
13. skype, Twitter, uni work etc.)
How did participants introduce themselves? Manon, first to respond, mentioned her role as a MHP, and then her past experience as a MHSU. Then Emily, introduced herself by her role on the course. Ray elaborated on his open-ended suggestion of introducing oneself (line 1), with a prompt "so how have people used the Internet?" (line 7), tied to the course aim of anonymity, including the possibility of not disclosing their status as MHP or MHSU. Sharpeye also oriented first to her MHP role, and then to her Internet use. In this course (and in the others), MHPs posted first, and set expectations. While there was opportunity for not disclosing status as MHP, MHSU (or both), the first posters, the MHPs, raised this themselves, consistently, as a relevant part of their identity on this course. Moreover, their way of talking-the things mentioned, and their language-reflected their MHP identity. In mentioning her service user experience, Manon drew on a medical discourse, couched in the language of the service providers: "experienced a bout of depression", "had support from the services". Mole talked about her MH use (line 10), then her forum and technology experience. The minimal punctuation and casual use of capital letters is standard chat forum typing [28
], but contrasts with the more formal posting of the two MHPs.
The researchers, Ray and Emily, tried to frame their questions neutrally, being interested whether anonymous online participation would overcome distinctions between "service provider" and "service user". Participants' positioning as MHP or MHSU may be expected during a round of introductions for this course, but it is notable that many participants, and especially MHPs, reiterated this throughout the course.
Ragdoll (C1)"however I am not a patient"
Hero (C2) "I wonder if as a MHP I am too used to careful wording of letters and find writing spontaneous text quite difficult"
Participants demonstrated that MHP/MHSU status was relevant, even though not explicitly requested. In this opening extract, we see both explicit orientation to a position, plus positioning by utilising medical expert or user experience discourses.
Format and interaction
A regular conclusion from comparisons of synchronous and asynchronous discussions is that synchronous interactions are useful in establishing social bonds, "a greater sense of presence and generating spontaneity" [29
], while asynchronous discussions are useful for learning- or task-oriented communications [30
]. In this intervention we used a mixture of synchronous and asynchronous formats, which provides the opportunity to compare the two. There were slight differences in posting frequency by MHPs and MHSUs in webcast posts (synchronous) and discussion forum (asynchronous)-an overall average of 11 webcast posts by MHPs and 13 by users, and an average of 7 forum posts by MHPs and 5 by MHSUs. Our main focus is however on the ways
people post in each format. Participants were asked to visit a website offering self-help for depression "Living Life to the Full" http://www.livinglifetothefull.org.uk
and comment on their experiences of similar sites:
Extract 2: Course 1, Webcast (synchronous) discussion, CCBT (computerised cognitive behaviour therapy)
1. Alpaca Last time i tried cognative therapy it just made everything worse, to me being told
2. that i was'thinking about things wrong' just added to my negative feelings about myself.
3. Astra I have used mood gym but found the whole thing very frustrating! Because I found
4. the systm hrd to use, and I found it so impersonal
5. Hawk i'll have proper look later when there's more time
6. Shell shouldn't using a CCBT site only really be tried if CBT in general has been
7. recommended as a treatment
8. Reflector I think I might find the front page of Living Life to the Full quite text-heavy if
9. experiencing very low mood
10. Hiker Is that part of why the someone supporting is so important-because these sites
11. can feel impersonal?
12. Astra Shell: i was recomeded to use it, but i tink your right
13. Reflector Hi Hiker-yes I think support is vital for (1) guidance through the process and
14. (2) if a peer, understanding where you are coming from in a personal way
In this discussion, Alpaca and Astra described their experiences of and feelings about using therapy (real life, or online "mood gym"), and the effect on their mood, thereby providing user perspectives, or 'experiential" accounts of the therapies. Shell subsequently argued that a therapy should be recommended. In contrast to the experiential responses, Reflector and Hiker posted more formally, conventional punctuation, using medical expertise or language, e.g. "if experiencing very low mood" (line 9). Astra (Line 12) responded directly to Shell. Reflector's second post (lines 13-14) is a direct response to Hiker's question with numbered points.
"Listening" to other participants
On a webcast it can be unclear whether posts are in direct response to the original question, or in response to a later post, but participants indicate this in various ways. Some referred directly to others' posts by name (lines 12, 13), but also by "mirroring" the terms used-Hiker (line 11) repeated Astra's word "impersonal" (line 4), and Astra (line 12) repeated Shell's word "recommended". The "thread" of the discussion was thus picked up, in a fast synchronous format, participants demonstrated they were responding to other posts, not just directly to the original question-an indication that, as hoped, MHPs and MHSUs were "listening to" each other.
The above extracts were from the synchronous webcast. Extract 3 is the related asynchronous discussion over the following week.
Extract 3: Course 1, asynchronous discussion, CCBT
1. Emily Wed 17:00: Does anyone have experience of using or recommending Living Life To
2. The Full or Moodgym, or any other CCBT? Describe and discuss those experiences. If no
3. experience in the group, then discuss whether you see a role for this, and why (perhaps) you
4. have not used or recommended it up to now
5. Alpaca Wed 22:00: Personally i haven't used them up until now because i didn't know that
6. they existed. It seems like a good concept, but from what people have said earlier, doesn't
7. apply to everyone in a positive way.
8. Puff Thu 9:14: I have used Mood gym a little but as I said I found it a little awkward to use.
9. It is also about what your state of mind at that time as well, how positive you are when you
10. start. I think there is a place for them though and as things develop, surely they will just get
12. Ray Thu 9:45: Puff I was wondering if you can remember in what way was it awkward?
13. You probably know that MoodGym is Australian in origin, whereas LivingLifeToTheFull is
14. British. I don't know if that makes any difference at all. Both have been'tested' in various
16. possibility for people with depression (long description of results of trials here)
17. Emily Thu 13:34: Hello, here's a summary of last night's second discussion:
18.-LLTTF-Text-heavy content can be off-putting, some content can add to negativity.
19.-MoodGym-Can be frustrating, awkward to use as impersonal and formulaic.
20.-A mixture of experiences in using Computerised Cognitive Behavioural Therapy.
21.-Severity of condition and present state can affect CCBT usefulness.
22.-Suggestions that CCBT should only be used if personally suitable type of therapy and on-
23. to-one support to monitor if it's helpful or not.
24. Some willing to try particularly if personal therapy waiting lists are long.
25. Hiker Thu 20:03: I'm going to have a look at them. Haven't used them up to now because I
26. see them as aimed at mild to moderate and thats not my field. If I used them it would be to
27. do it alongside someone.
28. The evidence for CBT is always hard to compare with other approaches. My gut feeling is
29. that used alone it doesn't make lasting changes. I'd expect the same here.
30. I feel I'm being very negative here but I don't mean to be, I think I'm just very cautious about
31. all these things. Do other people feel that way too?
32. Puff Thu 21:53: It was the keeping up the exercises bit. I am trying to remember why i
33. particularly found it awkward it was quite a while ago (but maybe for me its more that i
34. have a bad view of CBT in general). maybe using a few online methods together, like mood
35. gym with a skype session follow up or skype preceding it, Make it a bit more human. you
36. dont want to feel'palmed off' onto the internet, like your not worth bothering with.. there
37. needs to be some good explanation to its purposes/uses and support whilst on it..
38. Ray Tue 16:08: Given the comments by some of you about CCBT not being for you, I
39. thought I would have another look at the literature on acceptability and drop out from using
40. CCBT. There is a study which is a review of other papers, entitled The acceptability to
41. patients of computerized cognitive behaviour therapy for depression: a systematic review
42. (Psychological Medicine (2008), 38, 1521-1530.).
43. Here is the summary of their study: (long summary follows)
(No more posts on this thread).
Emily started with a question intended to suit both MHSUs and MHPs "used or recommended". This elicited two MHSU responses, Alpaca and Mole, drawing on their user experience. Ray responded to Puff, referring to NICE guidelines and medical trials. Emily then posted a summary of the synchronous webcast (Extract 2). Hiker (MHP) posted, responding to the "evidence", expressing her reservations, and finished with an open question, "do other people feel that way too?" (line 31). Puff returned and appeared (line 32) to answer Ray's question (line 12) about the way therapy made her feel. Nothing further was posted for 5 days, then Ray posted another CCBT literature summary, which was not responded to before the course closed the next day.
Researcher, MHP and MHSU expectations
We can note different expectations participants brought to the course. The researchers wanted to generate an online collaborative learning space, and acted as social hosts, "weaving" the threads [5
], while posting to open up the discussion and minimise hierarchies between participants. MHPs signed up wanting training, and to receive a certificate. MHSUs offered and compared "experiential knowledge". Did the MHPs orient to the MHSU's experiential knowledge? In each course, some topics attracted more posts from the MHPs (e.g. "would online therapy work?", "Useful websites"), topics which encouraged providing information and considering research. Other topics attracted more posts from MHSUs ("sharing patient records online", "barriers to Internet use"); who typically responded, as Astra and Alpaca did, from an experiential perspective. The researchers introduced the 'researcher' view, with literature summaries and links, in contrast to moderation on other sites which focused on supporting the MHSUs [13
]. The researcher intervention here was specifically concerned with learning and discussion, rather than support.
Extract 4: Course 3, asynchronous discussion: Who would benefit from online therapies?
1. Emily Wed 15:39 Are there particular groups of patients for whom the Internet would be
2. most useful? And are there other groups for whom the Internet would not be useful? What
3. are those groups and what are the differences?
4. Tranquility Sat 19:25: I'm thinking there are at least two useful groups-1 being those who
5. frequently use the Internet and who naturally turn to the Internet for information/
6. communication-Younger and middle aged people (HYPERLINK).
7. I think the second group would be those most likely to be advantaged by use-people with
8. social phobias, agoraphobia, those who work unsocial hours, people in rural locations,
9. people with disabilities or caring responsibilities. Perhaps the second group who might have
10. the most to gain?
11. Toucan Sun 18:37: I don't disagree with you Tranquility, but I do often question whether
12. the Internet is useful for those with social phobia/agoraphobia. I haven't come to the answer
13. myself yet, but I do wonder whether the potential of providing a less anxiety provoking way
14. of interacting with others is a double edged sword. As well as putting the individual in
15. contact with others, it could also reinforce avoidant behaviour. I suppose it comes back to
16. something I mentioned in the chat during the webcast-is our definition of social contact
Emily again posted an open question without explicit reference to status. There was a three day gap before the first reply; Tranquility categorised "two useful groups", with a supporting link. As with Reflector in extract 2, this post was framed as a considered academic argument. One day later, Toucan replied, starting with "I don't disagree with you Tranquility, but....", a formulation understood as a careful management of disagreement [31
]. Again the medical expert/academic discourse is noticeable, Tranquility and Toucan drew on professional ways of talking-"reinforce avoidant behaviour" (line 15). In this asynchronous discussion, there was more emphasis on the evidence, the professional view, and less of the experiential perspective.
Perceived proportion of MHPs and MHSUs
A primary motivation for this intervention had been the limitations of previous studies in engaging MHPs in online learning in a self-harm support forum. This led to the "course" format with a participation certificate, efforts to recruit more MHPs, and focused discussions. In course 3 (Extract 5) there were more MHPs (7:3).
Extract 5: Course 3, first webcast
1. Toucan - I'm not convinced that Internet use does reduce social contact, I think it
2. challenges our tradition concept of what can constitute social
3. Toucan - tradition-al even!
4. Lex-i think it easy to be drawn into other people's problems and feel sad by them and
5. have no outlet for them
6. Manon - but that's the problem, Toucan.. I have observed people loosing the
7. confidence in social situations with actual people, whilst feeling fine in the world of their
8. chat sites...
9. Milkyway - i worry as there are some dodgy ppl about
10. Milkyway - mental health sufferers can be very vulnerable
11. Manon - so what might go wrong, Milkyway? that you might get to know someone
12. who's dodgy...?
13. Toucan - Yes Lex, I agree with you. I think that when using discussion forums you can
14. find yourself in a role of not being able to leave a discussion or getting trapped into a helper
15. role. I have certainly experienced this issue with a service user
The positioning of MHSUs as the other, "very vulnerable" (line 10) is notable here. In this extract MHSU/MHP status is not immediately clear, but posters use of medicalised or academic discourses ("it challenges our traditional conception"), including formal ways of describing a problem "I have observed people losing their confidence in social situations"-again, positioning these people with problems as other people, observed not experienced. One of the few MHSUs on this course, Hawk, commented early on that "I feel outnumbered". The self-correction of grammatical inaccuracy (line 3) is a feature of formal academic discourse, in contrast to forum speak [28
]. Again we see how posters indicate they are "listening" and responding to others, with explicit references (lines 6, 11, 13) to others by name. The final extract comes from Course 1, in which 2 MHPs were outnumbered by 9 MHSUs.
Extract 6: Course 1, final webcast
1. Shell as a user i would have preferred a higher ratio of users:professionals
2. Ray Shell, yes the next one will have many more professionals. That was partly down to us
3. being rather late in getting the adverts out to professionals.
4. Shell @ray-no, i want MORE users
Shell's perception of many professionals is interesting, given the proportions on his course. Our analysis suggests several explanations for a perception of more MHPs, even in course 1 when they were in a minority, and though there were as many posts overall by MHSUs. MHPs tended to post first, setting interactional norms of using a medical or academic discourse. There was overlap of MHP/MHSU roles-several MHPs mentioned prior MHSU experience, and some MHSUs worked in health professions. Moreover, many MHSUs are veteran forum users, which may give them "contributory expertise" [32
] in their MH area.