Project 99 Full Report by Project99

PROJECT 99 EXPLORING INTERNET BASED APPROACHES TO SUPPORT YOUTH MENTAL HEALTH IN GREATER GLASGOW & CLYDE.

SNOOK

INTRODUCTION FROM THE PROJECT COMMISSIONER Project 99 – Exploring the potential of the internet & social media in promoting the mental health and wellbeing of young people in Greater Glasgow & Clyde There is now ample evidence that mental health and wellbeing for children and young people should be seen as major areas of public health focus. Work such as the Foresight Project on Mental Capital and Wellbeing demonstrates the importance of concerted efforts on promoting child mental health – with benefits both in childhood and in promoting health in later life. Over the last few years NHS Greater Glasgow and Clyde has been working with its local partners to develop a strategic approach to promoting the mental health and wellbeing of children and young people in our Board area. From this development work, the desire to strengthen the range of communication approaches that are used to connect with children, young people, their families and carers has emerged as a major issue. Linked to this, we have been tracking the emergence around the world of innovative approaches to use of new communication technologies as tools that have potential in promoting mental health and wellbeing.

Mindful of the pace of change in the fields of web and social media – in both technological and social terms – we were keen to create a process that would allow us to engage directly with young people. This would allow us to understand more about how they interact with this evolving world of communication, how they see mental health and wellbeing issues and to gain their insights into the kinds of tools, supports and approaches that would be most helpful to them. A coproduction approach seemed ideal to progress this agenda. Following adoption of a formal tender process, contract was awarded to a three agency consortium consisting of Young Scot, Snook and the Mental Health Foundation. With the active support of a multi-agency steering group, we have been delighted with how this initiative has been taken forwards by our ‘consortium’ partners, and particularly impressed with the enthusiastic and insightful contributions that have been made by young people.

We are confident that the analysis, mapping, shared experiences, insights, ideas prototyping, resource materials, and recommendations for change brought together by Project 99 provide an excellent platform for our multi-agency partnership to progress work in this field. Most importantly, this work demonstrates the need to continue working with young people as key partners. We are also keen to continue to connect with like-minded colleagues engaged in similar explorations, in order to provide the most effective support to children and young people. We welcome your reactions to the outputs of this work.

Dr Trevor Lakey, Health Improvement and Inequalities Manager (Mental Health, Alcohol and Drugs) Greater Glasgow and Clyde Health Board

CONTENTS CONTEXT

FINDINGS

Chapter 1: Project Outline

Chapter 2: User Case Studies

An introduction to the project’s scope and approach, with details on the project partners and outline of intended outcomes.

This section details stories and insights from interviews carried out with selected young people. All interviews have been anonymised.

1.1 Project summary 1.2 Summary of report recommendations 1.3 Project context 1.4 Project partners 1.5 Project approach 1.6 Outline of project outcomes

2.1 Greig’s story 2.1.1 Insights 2.2 Lisa’s story 2.2.1 Insights 2.3 Jenny’s story 2.3.1 Insights 2.4 Ben’s story 2.4.1 Insights

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Chapter 3: Insights through engagement sessions

Chapter 5: Findings through desk research

This section details the key insights that emerged through our engagement sessions with young people.

This section contains literature pointers and outlines the content of document 2 in this report, which is the culmination fo the research.

3.1 Insights relating to digital media use 3.2 General insights relating to youth mental health and attitudes 3.3 Insights relating to digital media use specifically in relation to mental health

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5.1 Summary of quantative data on internet use in young people 5.2 Summary of literature 5.3 Summary of practice 5.4 Summary of digital asset mapping

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Chapter 4: Outcomes of c0-design workshops This section presents the ideas developed by young people during co-design sessions. 4.1 The young people’s ideas 4.2 Development of 2 key ideas 4.3 Insights from co-design sessions

CONTENTS PROCESSES

RECOMMENDATIONS

Chapter 6: Research Processes

Chapter 7: Recommendations from Project Partners

This section outlines the methods utilised in conducting both the desk based research and the engagement activities carried outh with young people. 6.1 Overview of youth engagement throughout the project 6.2 Engagement processes 6.2.1 Description of activities used during engagement sessions 6.2.2 Description of activities used during co-design sessions 6.2.3 Engagement session risk management 6.2.4 Limitations of sessions 6.2.5 Use of social media 6.3 Desk research processes

This section outlines the recommendations made by the project partners as a result of the previously detailed findings. 7.1 Recommendations for development of digital assets 7.2 Wider recommendations 7.3 Recommendations for use of existing social media sites by the NHS

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APPENDICES Contained in the second document is a map of existing digital assets for mental health support, as collated by the project partners. 1.0. Digital asset mapping document 1.1 Description of how to use the document. 1.2 Explanation of map parameters 1.2.1. Explanation of audience catergories 1.2.2 Explanation of activity types 2.0 The illustrative map of digital assets 2.1. Map in full 2.2 Segmented map 3.0 Glossary of assets 4.0 Selected case studies 5.0 References 6.0 Appendices

As shown in this table of contents, for ease of reading, this document has been split into segments that may be read in isolation (following the first introductory chapter) depending on your specific interest. This document is interactive; by clicking the ‘READ’ buttons on this contents page, you will be taken straight to the relevant section of the report. Each chapter also has a title page, where again you will see the ‘READ’ buttons. These can also be used to navigate through the document and to skip chapters. The buttons appear as below:

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CONTEXT CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

CHAPTER 1 PROJECT OUTLINE

CHAPTER 4 OUTCOMES OF CO-DESIGN SESSIONS

CHAPTER 5 DESK RESEARCH FINDINGS

THIS SECTION DETAILS THE CONTEXT, SCOPE AND INTENDED OUTCOMES OF THE PROJECT.

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

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1.1 PROJECT SUMMARY & CONTEXT

“COMMITMENT 6: DURING THE PERIOD OF THE MENTAL HEALTH STRATEGY WE WILL DEVELOP A SCOTLANDWIDE APPROACH TO IMPROVING MENTAL HEALTH THROUGH NEW TECHNOLOGY IN COLLABORATION WITH NHS 24.” Mental health strategy for scotland, 2012-2015

Through this project, Greater Glasgow & Clyde NHS and its local partners are looking to explore the potential of the internet, social media and mobile technologies in promoting better mental health and wellbeing for young people. A collaborative approach is employed, working closely with local young people. Within the scope of this project, the age range of those we engaged with was between 15 and 21. It is recognised however, that much younger people need to be included in any further work. The project intends to provide a basis for discussion with stakeholders in the board area. Central to it is the hosting of codesign events with young people across the area, in order to explore and discuss their use and desired use of the internet in relation to mental health. The synthesised output from these events, presented in this report, will then give a direction for potential future work in the board area, and some practical suggestions for relevant workforce

groups for engaging with young people using the internet; social media in particular. Improving the mental health and wellbeing of children and young people has been highlighted as a priority action area in a number of health strategies and policies.1 These policies come at a time in which a growing body of evidence suggests that the current economic climate is adding to level of distress and burden experienced by young people. This project arose as an agreed action area in the approved strategic programme for Child and Youth Mental Health Improvement for Greater Glasgow and Clyde. It aligns with Commitment 6 of the Scottish Mental Health Strategy 20122, which stresses the intention to use new technologies in the improvement of mental health nationwide. We have now entered the age of the ‘digital native’; young people have grown up with digital, mobile

technologies. Accordingly, new digital technologies and social media are being used across the globe to expand the range of support available for mental health and wellbeing. Many such initiatives have already been advanced in the UK, including the development of health related apps for mobile devices. Examples of such initiatives have been comprehensively (although by no means exhaustively) mapped in this report. They can be found in the appendices as a separate document. The reliance of young people on digital technologies - the web and social media in particular - also presents new challenges in the mental health sphere. Whilst the web may be an extremely positive tool in supporting mental health improvement, it also allows for the rapid dissemination of potentially damaging material and affords new kinds of negative behaviours (such as cyber-bullying and obsessive use.)

Examples include: ‘Towards a Mentally Flourishing Scotland – Strategy and Action Plan’, 2009-2011, Scottish Government; ‘No Health Without Mental Health’ strategic framework for mental health improvement for Greater Glasgow and Clyde - 2010; ‘Keeping Health in Mind’, Director of Public Health Report of 2011 for the Greater Glasgow and Clyde area. 2 Mental Health Strategy for Scotland, 2012-2015: http://www.scotland.gov.uk/ Publications/ 2012/ 08/9714/downloads

As such, this project aims to explore the excellent potential of digital technologies as a means for supporting mental health improvement, and the positive aspects of young peopleâ&#x20AC;&#x2122;s participation in online activities; such as the development of creativity, sharing self-generated content and engagement with civil society. However, means to safeguard young people from negative patterns of use will also form a crucial simulataneous consideration.

It also takes the view that digital and online behaviour should not be seen in isolation. Young peopleâ&#x20AC;&#x2122;s digital lives should be considered in interrelation with their work, home, school and leisure time, as opposed to emphasising an artificial distinction between online and offline worlds. Such a holistic approach aligns with recommendations made by Collin (2011)3 in a key review that will be discussed further in our literature summary (see Chapter 5).

Collin, P , Rahilly K, Richarson I, Third A(2011) The Benefits of Social Networking Services: A Literature Review. Young and Well CRC, Melbourne http://www. yawcrc.org.au/knowledge-hub/publications (accessed July 2013)

1.2 SUMMARY OF RECOMMENDATIONS

The main body of recommendations drawn from the findings of this report can be read in Chapter 7. However, here we provide a concise summary of the key points.

PROCESS 1. A co-design approach,

with a framework for on-going engagement with young people is the default for any projects seeking to develop digital assets for youth mental health.

2. GGC NHS should develop

a youth engagement framework to support this on-going engagement, with potential internships for young people.

DIGITAL ASSETS A digital springboard (or gateway) consisting iterative, user-centred content focused on supporting mental wellbeing (not solely focused on mental health issues) should be developed. This would ideally contain the following elements:

Within this digital springboard specific areas should focus on supporting individual young people, including:

Emergency 24 hour Instant Messaging tools

1. Service directory 2. Advice directory 3. Tool kit for wellbeing 4. Links to and connections

Empathy tools

Access to forums for group support

Access to tools which help maintain good mental health

Practical day to day tips on managing common mental health problems

with wider services

WIDER IMPACT 1. GGC NHS should develop an emotional literacy programme as part of educational curriculum.

2. A ‘first responder for mental health’ training scheme should be developed to allow support within schools.

3. A campaign should be

developed through which young people are encouraged and incentivised to find ‘a third space’.

NHS USE OF SOCIAL MEDIA NGS GGC should appoint young people as social media managers for peer related content.

NHS GGC social media strategy should include:

1. Creation of interesting,

relevant, engaging content which young people would want to share

2. Find appropriate health related and user-generated content to share

3. Monitor and respond

to trends (both positive and negative) with appropriate content

4. Blog developments in digital asset strategy

1.3 PROJECT PARTNERS and young people programme,

Project Partners Mental Health Foundation, Snook and Young Scot have been commissioned to carry out this time-limited project in partnership, concluding in November 2013. Mental Health Foundation is a leading UK mental health charity, connecting policy, practice and research agendas to support change and campaign for better mental health for everybody. Across two Scottish offices, the organisation

focuses on mental health and inequalities, leading the Scottish Mental Health Arts and Film Festival. From November 2013, the Foundation will be working in partnership with SAMH to deliver the renewed â&#x20AC;&#x2DC;see meâ&#x20AC;&#x2122; anti-stigma programme, which will include increased capacity to support social movements and co-designed campaign approaches with stakeholders. Across the UK the Foundation has a major children

which includes Right Here, and the Innovation Labs programme. Snook have developed a range of creative tools and methods which help people reflect on and articulate their service experiences, uncover insights into barriers to - and opportunities for - service improvement, and re-imagine new design solutions for improved service experience.

Young Scot is the national youth information and citizenship charity for Scotland, specialising in youth engagement. They provide young people with a mixture of information (which includes mental health related issues), ideas and opportunities to help them become confident, informed, active citizens.

1.4 SUMMARY OF APPROACH Approach The projectâ&#x20AC;&#x2122;s approach is two-fold. Firstly, it involves a desk research segment to create an illustrative snapshot of the digital media-mental health territory. The snapshot highlights key examples of services and innovations, and identifies existing literature reviews, practice guides and research of note.

case study interviews, engagement activity sessions and surveys form the initial insight gathering stage, with the aim of understanding young peopleâ&#x20AC;&#x2122;s digital and social media use, their experiences of mental health related issues and the kinds of support they have had in this respect.

Secondly, the project takes a participatory approach, working with local young people. A series of

This is followed up by co-design sessions with a core group of young people identified during the

engagement sessions. The outcomes of these sessions is a series of co-produced ideas and recommendations.

1.5 CASE FOR A CO-DESIGN / CO-PRODUCTION BASED APPROACH The health service rationale The Scottish Government recently outlined a serious commitment to engaging a wider range of people in the co-design and co-production of public services in the Christie Commission Report (2011). This was followed in 2007 by the Scottish Government’s Better Health, Better Care Action Plan which made a commitment to “a mutual NHS where patients and the public are confirmed as partners rather than recipients of care.” Nationally and internationally, co-design and coproduction of health and wellbeing services, where people take more responsibility for self-care, are recognised as the only solution for sustaining an already overloaded healthcare system (Wanless, 2004). Most recently Nesta (2013) make the case for a People Powered Health programme that offers the opportunity for “a redefined relationship, a partnership of equals between people and health care professionals. These relationships are trusting, purposeful and oriented to the needs of the individual and not the system.” Marmot suggests that to reduce

health inequalities we must ‘Enable all children young people and adults to maximise their capabilities and have control over their lives.’ (Marmot 2010). An increase in participation can lead to more appropriate and accessible services, while increasing social capital and people’s self confidence and health-enhancing attitudes (Popay, 2006). Bate and Robert (2007) have championed the use of a design approach to healthcare service improvement under the theme of ‘experienced based design’. Precedent for such an approach specifically relating to the health of young people and digital technology has been set in Australia. The Australian Cooperative Research Centre for Young People, Technology and Wellbeing (YAW-CRC) was founded in 2010 to bring together academic, voluntary sector and commercial partners to collaborate on research and innovation in young people, digital and mental health research. The organisation has added substantially to the evidence base through developing, piloting and evaluating methods of engaging young people and other

stakeholders in the field. It has recently produced a guide for applying participatory design principles to the development of digital tools for young people in relation to mental health and wellbeing.1 Co-design and co-production: the design approach Co-design as an approach in the design tradition has evolved from Scandinavian models of participatory design developed to enable employees and employers to work together to co-design better working environments. (Ehn, 1993). The methodology’s roots are grounded theory by virtue of the iterative approach, where insights gained and themes identified in each cycle of engagement then inform and are explored in the proceeding stages (Glaser and Strauss, 1967, Sanders and Stappers 2008). The Design Council defines co-design practised by designers as: • Tools used by designers to engage non-designers by asking, listening, learning, communicating and

creating solutions collaboratively. • A community centred methodology that designers use to enable people who will be served by a designed outcome to participate in designing solutions to their problems. • A way to design a solution for a community, with that community. Emphasis is on delivering improvements and innovation through a ‘do-with’ not ‘do-to’ approach. The co-design process explores and values differences in opinion and places particular emphasis on understanding the everyday lived experience of ordinary people. The designer facilitates of other’s creativity, using design tools and methods to stimulate a dynamic, creative environment, within which others are able to generate ideas.

Participatory Design of evidence-based online youth mental health promotion, prevention, early intervention and treatment (Young and Well CRC) http://www.yawcrc.org.au/knowledge-hub/ publications

References Bate, S.P. and Robert, G. (2007). Bringing user experience to health care improvement: the concepts, methods and practices of experience-based design. Oxford: Radcliffe Cottam, H and Leadbeater C. (2004). HEALTH: Co-creating Services, RED paper 01. London: Design Council.

Ehn, P. (1993) Scandinavian Design: On Participation and Skill in Participatory Design: Principles and Practices. Routledge

Marmot, M. (2010) Fair Society, Health Lives: The Marmot Review. Strategic Review of Health Inequalities in England post-2010.

Sanders, E. B. N. and Stappers, P.J. (2008) ‘Co-creation and the new landscapes of design’, CoDesign, 4: 1, 5 — 18

Glaser, Barney G. and Strauss, Anselm L. (1967) The discovery of grounded theory: strategies for qualitative research. Chicago, Aldine.

Popay, J. (2006) Community engagement, community development and health improvement: a background paper for NICE (available on request by emailing lorraine.taylor@nice.org.uk)

Scottish Government (2011) Commission on the future delivery of Public Services

Horne, M. and Shirley, T. (2009). Coproduction in public services: a new partnership with citizens. London Cabinet Office Strategic Unit.

Wanless, D. (2004). Securing Good Health for the Whole Population. HMSO. London.

1.6 OUTCOMES AND DELIVERABLES DELIVERABLE 1:

DELIVERABLE 2:

DELIVERABLE 3:

This includes:

Working through co-design sessions, we have produced advice for young people, in part by young people, that will help them to utilise digital and social media in order to aid positive mental wellbeing. These guidelines will be presented in an imaginative and attractive way, through a short series of illustrated ‘postcards’. These may be printed, but will be flexibly designed for optimum digital dissemination through a variety of channels, critically including the social media networks utilised most frequently by young people. The digital ‘postcards’ will include links to related content and websites.

Taking place on 14th November 2013, the project and its findings were presented in a lively interactive format to interested parties. Selected young people and key external speakers were invited to speak.

PROJECT REPORT

• The project process in full detail. • Insights from the case studies, engagement activities and co- design workshops in full detail. •

Ideas from the co-design sessions with our team of young people. It is important to stress that these ideas are not finalised, polished solutions but their feasibility and sustainability have been assessed and inform the final report recommendations.

• A body of recommendations, falling into three categories:

1. Recommendations for development of digital assets

2. Wider recommendations

YOUTH GUIDE

PROJECT PRESENTATION

3. Recommendations for use of existing social media sites by the NHS

FINDINGS CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

CHAPTER 4

THIS SECTION DETAILS THE STORIES AND INSIGHTS GATHERED THROUGH INTERVIEWS CARRIED OUT WITH SELECTED YOUNG PEOPLE. ALL INTERVIEWS HAVE BEEN ANONYMISED.

OUTCOMES OF CO-DESIGN SESSIONS

CHAPTER 5 DESK RESEARCH FINDINGS

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

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2.1 CASE STUDY: GREIG, 19 Digital Life Greig is a young carer living with his family in Govan. His mother lives with mental health problems and he and his younger brother are both on the autistic spectrum. He also has severe dyslexia. Greig often has to share access to the internet with the rest of his family.

Greig has a mobile phone, but it is not a smartphone. Due to his severe dyslexia he chooses to phone rather than text, unless he is able to reply with a one or two word answer. Therefore if someone texts him, by and large he will phone them back.

rarely posts things himself. If sent a message he will reply as soon as possible - he hates “ignoring people” - but he is unlikely to instigate many conversations. He also spends a lot of time playing facebook based games.

He is able to access the internet through the shared family desktop computer at home, and through a laptop he shares with his brother. This often causes arguments as to who gets to use the internet and for how long, and denies Greig privacy and autonomy in his use.

Aside from this, he uses internet for research for his college work. Due to his dyslexia he will avoid websites with large amounts of text and options, and those with complex layouts. For this reason he never reads blogs; video is his preferred medium for obtaining information.

He has his own Xbox and is able to access YouTube via Xbox Live (which allows Xbox users some internet access and social networking). His YouTube use is heavy, with sessions lasting hours. It is common for him to be watching videos on YouTube all evening from 5pm until 1am. YouTube is the site he uses the most by far. Aside from Youtube, Facebook and online games are central to Greig’s internet use. His use of Facebook is passive; he likes to scroll through what his friends post and keep up with news from the pages he follows. He very

Greig makes very little use of digital and social media in the direct management of his mental wellbeing. In the past he has attempted to search for information on Asperger’s Syndrome and his mother’s condition. However, he found very little that was of much use to him as someone managing his own condition on a daily basis, and even less that was in a form that was easy for him to digest. He does receive email updates from a few support groups that he has been signed up to by his college, but most he treats as spam.

“MY BROTHERS SAY I SPEND WAY TOO MUCH TIME ON YOUTUBE AND IT CAUSES ARGUMENTS SOMETIMES. I DON’T THINK I DO! WELL, I MEAN ... ITS NOT LIKE I HAVE ANYTHING BETTER TO DO.”

2.1 CASE STUDY: GREIG, 19 Mental Wellbeing Greig lives with Asperger’s Syndrome, but was not diagnosed until high school. He had experienced an extreme trauma as a young child; his behaviour was attributed to this and the Asperger’s was masked. His mother also lived with mental health difficulties which - according to Greig - led her to “dramatise and exaggerate” his symptoms. Primary School was extremely difficult. There was no awareness or support for either his or his mother’s condition. He became extremely frustrated and disruptive as a result. He found it difficult to make friends.

Photo by George Redgrave under a Creative Commons License

At High School things improved slightly following accurate diagnosis. The school were also aware of his mother’s condition. However, they did not have adequate support measures in place for him. Learning was very difficult compounded by his severe dyslexia. He continued to have angry outbursts. This was made far worse by the fact that he was being bullied by many of his classmates; in the face of the bullying he began to strike out. The

school punished Greig rather than his bullies. He was told to stay home if he woke up in a dark mood, knowing that this would make him more likely to have an outburst. This solution was both a relief and a frustration for Greig. He was eventually provided with a learning support teacher, but only during home economics class, as a precaution to ensure he wouldn’t become angry whilst using kitchen implements. In the end he left mainstream education to attend a school specialising in support for people with autism. The teaching better suited his style of learning - he was taught largely through the use of puzzles, games and quizzes - and helped greatly by the designated ‘chill out’ room. However, he still felt slightly out of place, feeling that he was probably one of the most intelligent students and a little held back.

GROUPS

EDUCATIO N

STAT UTO RY S

S IV CE ER

SUPPORT SE RVICE PRO VID ERS 3RD SECTOR SUPPORT

PRIMARY

COMMUNITY & CULTURAL GROUPS

SOCIAL CARE

GREIG始S CONTACT WITH SERVICES.

HEALTH CARE ACUTE

PRIMARY CARE

VIC

Services user has come into contact with for mental health support.

SER

KEY:

TERTIARY

VIC

SEC

A ND

2.1 CASE STUDY: GREIG, 19 “THE KIDS AT CHURCH SAY I KEEP THEM HAPPY, BUT IT’S THE OTHER WAY ROUND.”

As Greig receives a lot of support in his own life, it is vital for his wellbeing that he is able to help others in return. However, it is also important that he does so in a supported environment, to ensure that he doesn’t take on other’s burdens as his own and to manage any ill effects he experiences from hearing other’s problems.

He is now in college and continues to receive learning support, but finally feels more in control of the management of his condition and home situation. He attributes this improvement to the support he has received from a Young Carers group and from his Church. He joined the Young Carers support group when he was 13 and attends weekly group sessions there. He is able to contact the support workers at any time; whilst they might not be able to meet him immediately, they will always make an appointment to see him straight away. The head support worker texts or calls Greig at intervals to see how he is getting on, without prompting from him.

community there. Perhaps the most important aspect of his church going is his voluntary work as a youth group leader. He often supports the young people with their problems, and recognises that this ability to help others in return is vital to his own sense of wellbeing.

He describes the Young Carers group as family, and even though his peers at the group “drive him mad sometimes” their friendship and community is extremely important. He is the longest standing member and enjoys a kind of senior status. He also attends Church twice weekly and volunteers as a youth worker there. He feels able to relax and be truly himself at Church and enjoys the kind, caring nature of the

2.1.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM GREIG. Private internet access

Video

“We’ve just got a family computer ... it causes arguments ... who gets to go on when, and how long I’ve been on it for!”

Video is an inclusive and engaging medium for information dissemination. In our engagement sessions, YouTube (alongside Facebook) was found to be the most popular social media site.

Not all young people possess a personal device with which to connect to the internet; they may be sharing access with parents, siblings, classmates. This affects the autonomy and privacy of their internet use, impacting upon what they search for and interact with on the internet, and how long they do so for.

Text messaging Despite the social media revolution, text messaging or now BBM (Blackberry’s instant messaging service) seems to remain a key part of direct, one on one communication for young people.

Gaming

“The games are what I like best about Facebook ... sometimes I’m on there for up to a few hours at a time.”

Increasingly, young people (particularly young men) are accessing the internet through games consoles and some games include social media elements. Many young people spend very long hours gaming and it could prove a useful means by which to access socially isolated individuals.

Continuous social media use

Social media and news

“My brothers say I spend way too mcuh on YouTube and it causes arguments sometimes. I don’t think I do! Well, I mean ... its not like I have anything better to do!”

“I like that I get to know whats happening [on Facebook]”

The excessive amount of time Greig spends online in the evening was found to be common amongst the young people taking part in our sessions. Whilst they may not be actively trawling the internet, they may be checking Facebook and other such sites every few minutes for this duration. Many echoed his contradictory stance; initially denying an excessive use of social media sites, but afterwards seeming to show vague feelings of guilt or regret for the amount of time spent, and to see that time as wasted.

Social media sites seem to be young people’s main source for news; be that about friends and family or current affairs on a larger scale. See page 96 for a further evidenced discussion on the importance of media literacy.

See page 101 for a further evidenced discussion of gaming.

2.1.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM GREIG. Passive vs active users

“I do post things on Facebook sometimes, but its mainly to reply to things that other people have posted. I reply more than I post.”

Young people talk about social media use as falling into two camps, with users being described as either ‘a talker or a stalker’. ‘Talkers’ are active users, who generate and disseminate a lot of content. ‘Stalkers’ are passive users, consuming content created by the ‘talkers’. Individuals fit the catergories to varying extent and may shift between them depending on various factors.

Information Overload Young people are constantly subject to information overload; competition for their attention is fierce. Fast judgements will be made as to the interest of any information. Certain content and trends will stand out from the noise and “go viral” amongst young people, rapidly being disseminated through the sharing of links. What kind of information this will be is quite unpredictable and the factors for this require further examination.

2.1.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM GREIG. Negative framing of mental health

“My mum’s got mental health ... ”

When describing his mother’s situation, Greig says: “she’s got mental health” - meaning that she is mentally ‘unhealthy’. This was a common turn of phrase and mentality at our engagement sessions; mental health is by default viewed in the negative and as something that is only relevant when you are unwell.

Bullying and mental health

Diagnosis

Expertise amongst young people

Bullying and mental health problems seem to go hand in hand for Greig and the young people at our sessions. Bullying was almost classed as a mental health problem in its own right, rather than a cause of difficulties.

Having a concrete diagnosis can be regarded by young people as a critical point of change in the young person’s mindset and in the way in which they will seek and gain support. The effect of a diagnosis may not always be clearly positive or negative, but can cause a shift in experience and framing.

Greig has made himself something of an expert on mental health, helping him contextualise his situation. He has taken various courses on the subject and demonstrated impressive and extensive knowledge and interest. This was also the case of a few young carers we spoke to during our engagement sessions.

Mediation through parents Inconsistent support in schools “It took the doctors a while to figure out there was something wrong with me ... because my mum’s got mental health as well, the way that she would tell them would be ... dramatised.”

A young person’s interaction with a GP or other medical professionals is often mediated via a parent. This will more than likely alter/restrict the information the young person is willing to share. See the ‘Doc Ready’ example on pg 17 of the mapping document in the appendices.

“Apparently my brother is getting better support than I did in mainstream school now ... that’s only because they’ve got a different headteacher.”

The availability and quality of support for mental health issues is not consistent across schools. It will often depend on individual teachers and workers and the priorities of the heads of school.

2.1.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM GREIG. Value of support groups

“... I’ve been coming here [to GAMH] longer than most of the workers! I like that they are there to give you the support when you need it. They can’t always give it to you straight away, but they give it when they can.”

Greig and all the young carers we spoke to found the Young Carer support groups extremely important to their well being. The success can perhaps be attributed to these factors: • Able to contact a careworker at all times via phone, text or email and receive a quick response. • The onus of taking the step to ask for help is removed, as the support workers will call or text to check up at intervals. See page 108 for further evidenced discussion of these points.

for vital peer support. Importantly, this support is within a controlled environment, managed by care workers. • Mixture of workers: some just a bit older and trained (who become older brother/sister figures) and the ‘mother figure’ that is the lead care worker.

Helper Theory

“The kids at church say I keep them happy but its the other way round.”

For those receiving a lot of support, being able to help others in return is important for their wellbeing. It creates a sense of balance, helps prevent the young person from becoming a passive ‘victim’ and allows them to actualise (and better understand through sharing) some of the advice they have received themselves.

The third space

“I’ve got my church ... to keep me going. I go twice a week and I’m a leader at the youth group as well.”

Having a ‘third social space’, a space of shared interest, with friends and peers other than those from the ‘first space’ that is home and the ‘second space’ of school or college, is important for wellbeing. The third social space helps a young person to define who they are and to meet other people who have also chosen that particular space. See The Mental Health Foundation’s work on the ‘Third Space’ for a further discussion.

• Encouraged to attend meet ups at the centre with other young carers

2.2 CASE STUDY: JENNY, 24 Digital Life

“I LIKE TO UPLOAD AN IMAGE OF SOMETHING THAT’S MADE ME SMILE, SOMETHING TO BE GRATEFUL FOR, EVERYDAY. IT SOUNDS CHEESY BUT IT KEEPS ME GOING.”

Jenny has been in the mental health system since the age of 14. In the past she has been seriously ill. She became anorexic, leading to psychosis and suicide attempts. She has been hospitalised on several occassions. She is now on stable ground and feeling healthy. She works full time in the third sector; she uses her lived experiences, and recounts her personal story in a professional context. She lives with her parents, and they provide her with great support, helping her to self manage and to keep relapse at bay.

Jenny accesses the internet through her smart phone and personal laptop. She mainly uses her laptop for work purposes, so prefers to use her smart phone in the evening for ‘leisure’ web use. She is constantly connected to Twitter and Facebook through her phone and feels dependent on it, becoming anxious if she ever forgets it. Jenny uses social media very actively, generating a lot of content. Her use when she was ill is very different from now. Currently, aside from her professional engagement with social media at work - she has to keep a Facebook page and Twitter stream updated and uses Youtube as a research tool - she describes her main use as uploading comical videos of pets and recounting humerous details of her day . Being conscious of using digital media positively has been a part of Jenny’s recovery. She makes a point of uploading a positive image everyday. She uses apps to aid her sleep and relaxation, although says that when having a bad day she does begin to use a calorie counting

app. She is able to self regulate, however, always deleting the app when she feels stronger. She keeps an open blog, making sure to keep it as a positive account of the successful management of her mental health problems (although rarely writes on it.) When ill she would use online journals and blogs obsessively to track her weight, food consumption, exercise and negative “rants”. The frequency of use increased when she got her own laptop and no longer needed to use the family computer. She developed a cycle of creating private blogs, then giving out the password, but later deleting the blog after deciding she didn’t want it read. The longest she kept a blog was two years, and described eventually deleting it as cathartic. She would also look up readliy available ‘thinsperation’ videos and set exercise reminders on her phone. She would use forums, seeking vital support from fellow sufferers. However, it was easy to become trapped in a competitive negative spiral; “people were trying to get iller than each other”.

2.2 CASE STUDY: JENNY, 24 Mental Wellbeing Jenny became seriously unwell when she was 14. She had begun to self harm and develop suicidal thoughts. At school she would frequently break into hysterical sobbing during lessons. Her behaviour was deemed ‘disruptive’ and as a result she was intially sent to the Behavioural Support Unit (which was commonly known as the ‘Bad Boys Unit’). Although it was a relief for her to be taken out of mainstream lessons, she found it understandably difficult in the ‘Bad Boys Unit’ and began working from home. Her parents stayed at home to care for her and took her to see a GP; initially she was diagnosed with anxiety, prescribed medication and told to eat healthily. The support she received from school at the time was mixed. A few teachers were extremely understanding, even offering outside tutoring. Others were less supportive, and she felt as she had been written off. This, however, only made her more determined to gain highers and go to University. She would have to attend many meetings with the heads of school and an educational psychologist,

who insisted that she must be being bullied, despite this not currently being the case. Her condition was not improving , and very soon she was referred to CAMHS. She received CBT and for a while her eating disorder went unnoticed due to her deliberate wearing of baggy clothes. When it was recognised, she began seeing a dietician in addition to the head psychiatrist. However, these sessions didn’t feel very helpful. She already felt she knew a lot about food and how she should be eating; having the desire to apply this was the problem.

externalise elements. Her parents also appreciated meetings with the pyschiatrist, as it helped them to understand what was going on. However, there were some major problems in Jenny’s eyes. Despite getting on very well with the head psychiatrist, she felt he “knew a lot about illness, but just didn’t understand teenage girls.” The main issue, however, was the disconnect between CAMHS and the wider services Jenny was using.

Jenny stayed with CAMHS until she was 20, and had mixed experiences. In her words: “Well, do you know what, it kept me alive. So I can’t say it was totally unhelpful ... its difficult to know what could have been done differently.” She found practical input most valuable; being helped to make a list of things to do that would help her get back to some kind of normality - building up to leaving the house etc - made recovery seem like a practical process and to help her

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2.2 CASE STUDY: JENNY, 24 Whilst within CAMHS, Jenny was also visiting her GP frequently and at some points was admitted to different hospitals. The services, however, didn’t talk effectively to one another; neither would know entirely what care medication she had received. Jenny’s GP was unaware that she had been discharged from hospital. The onus was on her parents to act as connections between the different services. Once she left CAMHS, Jenny was supported by adult care. Her first visit to hospital felt especially difficult after this transition. At this point, her stays in hospital were long, and she would be sent to different hospitals each time. This felt difficult when the hospitals were located far from home.* During her lengthy hospital stays, Jenny found it impossible to keep in touch with friends, but her parents would visit every night. Sadly, this often triggered feelings of guilt as other patients were not receiving the same kind of parental support. These other patients became close friends - a makeshift “family” - and Jenny found their support invaluable at the time. However, she is unsure

now whether her lengthy stay in a specialist eating disorder unit in particular was beneficial in the long run; being surrounded by others with eating disorders for her created a sense of a negative spiral. Being discharged from these hospital visits always felt stressful and unsupported in that she would need to wait a week before seeing a psychiatrist: “well, ok, what do I do for that week?” Jenny described her illness as coming in phases. When at University, despite being quite physically unwell, her enjoyment of University life kept her going. Once leaving, the uncertainty made her illness more difficult to deal with emotionally for a period. However, her hospital visits began to get shorter, and finally were unnecessary as she became able to self manage effectively. She feels that her involvement in youth volunteer projects has been a large part of her recovery. They gave her a sense of confidence, purpose, and worth. This lead on to her securing a full time job in the mental health sector. This feeling of being able to use her experiences to help others has been invaluable.

“YOU’RE TREATING ILLNESS, BUT THERE IS A WHOLE PERSON ATTACHED TO THAT.” Jenny feels that “whole person support” was missing from the care she was given by NHS services. She feels she should have been encouraged and aided to have a more active social life; instead she was told to conserve her energy. Now she feels that it is “all the non-medical things” keeping her healthy; her job, volunteering, properly structured exercise, massage and new friends.

*There were also disadvantages of being sent to the same hospital on consecutive visits. A few members of the nursing staff who recognised her when she returned for a short stay, made her feel - through throwaway remarks - that she would be in and of of the hospital on a permanent basis, doing little to inspire hope of recovery.

2.2.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM JENNY. Digital media ‘withdrawal’

Management of social media use

Blogging and online diaries

“I walked to the shop the other day without my phone. To start with I was like “Oh no, I forgot my phone.” But then it was actually so nice to go for a walk without my phone, when I stopped worrying about it ...”

“There was a lot of upsetting stuff online recently by this feminist - I can’t remember her name - talking about rape and violence towards women. I actually had to mute the hashtag because I was like “I just don’t want to see this on my stream just now. I was talking to a few people who did the same.”

“I had a blog I used everyday for two years ... but eventually I got rid of it because it was quite negative. Then I started another blog, but I mistakenly gave some people the password and realised I didn’t want them to read it, so I deleted that one too. ”

Some young people check their social media accounts and phones with such regularity that they experience withdrawal like symptoms and mild anxiety when they become unable to do so, even for very short periods of time.

The conscious and positive management of online behaviour is arguably as important as that of offline behaviour in relation to a young person’s mental health. Most young people are able to self regulate effectively. However, self regulation becomes more difficult and unlikely for vulnerable young people. Some tools - trigger filters, for example - already exist on social media sites to aid self management. See page 109 for a further evidenced discussion of perspectives on risk and vulnerability.

The keeping of diaries is not a behaviour restricted to the online world. However, the key difference in keeping an online journal or blog is that it is very rarely done in isolation from other users, and can be made entirely public in the click of a button. Even private blogs are likely to be hosted on a platform shared by countless other users, many of whom will be posting publically. This can have positive consequences for vulnerable young people using blogs, fostering a feeling of support if they read the posts of others in similar positions. However, these blogging ‘communities’ can be negative in nature; there are a many proanorexia and pro-self harm blogs in

existence, for example. There is also the possibility of attracting abuse and misplaced advice. There are also concerns that the level of digital literacy may not be high enough in many young people to enable an understanding of appropriate levels of identity sharing. See page 109 for a further evidenced discussion of perspectives on risk and vulnerability.

2.2.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM JENNY. Private internet access

Readily available negative content

Benefits and risks of forums

“I used Livejournal when I first got ill to track my weight going down and stuff, but I didn’t have it for long ... those were the days when you only had a shared family computer, so ...”

“The targeted ads on Facebook I find quite difficult ... I get a lot of the ‘Lose Two Stone In A Week’ type adverts ... sometimes I’m like, ‘Oh if they’re sending me this I must need to lose weight.’”

“You can think you’re doing everything right, everything positive ... BEAT is a good example, they’ve got their forums, you can’t mention numbers, you can’t mention food, all these things ruled out, but you can still see that people are competing, and thats just part of the illness ... You just see people trying to get iller than each other, and I think that will happen everywhere, in terms of eating disorders .... and same with self harm, I would say.”

In a development of the insight discussed following Greig’s case study, we see that negative effects can arise due to the recent proliferation of personal internet access amongst young people through smart phone and laptop ownership. The fact that young people are able to access the internet anytime and in their own personal space - away from a shared computer at home or school - allows negative online behaviours to go largely unchecked. The very knowledge that this is the case - that they are not being watchedcan lower a young person’s threshold of self regulation.

Content which is potentially damaging to a young person’s mental health is readliy available online. It is easy for a young person to find and access without constraint. Young people may also be exposed at some point to negative content that they haven’t purposefully looked for. This could be via posts left on Facebook streams by other young people, via links seemingly incongruous made through other unrelated content, or through viruses. Even the targeted advertisments on Facebook and other social media sites can prove damaging to vulnerable young people in certain circumstances.

Forums can provide important means of support for young people with mental health problems. The anonymity they afford means that many young people feel free to express thoughts and ask questions in a way that they may be unable to do with family and friends, due to various emotional barriers. Reading the comments of those in similar positions also allows them to contextualise their on situation and to feel less isolated, more understood. Some forum users can also provide invaluable positive advice. However, there are risks that are quite difficult to fully mitigate. Whilst the majority of users are very well intentioned, creating communities of vulnerable people can have negative effects.

Advice may be misplaced and even potentially damaging. Users may become overly dependent on and comfortable within the community, which could prolong recovery in some cases. See page 106 for further discussion.

2.2.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM JENNY. Facebook vs Twitter: use distinctions

“Self harm and suicide ‘threats’ seem more common on Twitter than on Facebook ... perhaps its not because there isn’t stuff on Facebook, just that you have to be friends with people to see it ... where as on Twitter it is easier to access this kind of stuff, it just involves searching a certain hashtag.”

In Jenny’s experience, self harm and suicide ‘threats’ seem far more prevalent on Twitter than on Facebook. She reflects that this may not in fact be the case; there may be a similar amount of such content on Facebook, but you are less likely to come across it due to the fact that you would have to be friends with the people posting such material in order to see it. The nature of Twitter means that you are able to see any such posted content via a simple hashtag search, and may even come across material accidentally.

Jenny’s and other’s use of Twitter that may mean that such material is in fact more prevelant. Young people’s Facebook networks contain close friends and, increasingly in the past couple of years, older family members. As we have seen for the preference for anonymous forum and blog use, many vulnerable young people are unlikely - or feel unable to - share deeply personal and negative thoughts related to their mental health in such company. Twitter networks tend to be wider, often made up of complete strangers or more distant social associates. Jenny speculated on this herself.

However, there are distinctions in

2.2.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM JENNY. Negative framing in schools

Support for parents

“I got sent to the ‘Bad Boys Unit’ ... for being disruptive ... I didn’t mean to be disruptive in class, but I guess that someone in hysterical tears in the corner is disruptive.”

“I can only imagine what is must have been like for my mum and dad, when they were the only people trying to keep an eye on me, trying to keep me safe”

A positive, practical approach is needed when addressing all disclosure of distress in schools. This enables and discouages earlier help seeking and helps frame response to serious incidents. Young people suffering from mental health problems should not be made to feel that they are receiving punishment as a consequence. This positive framing needs to be comprehensive and reflected in every step of procedures. Naming a unit ‘Behavioural Support Unit’, for example, is not enough if it is not seen in this way by the school pupils.

Supporting a young person through mental illness can place an great emotional strain on parents and the wider family. The strain can be practical and financial too, especially if time off work is required to care for their child. Whilst it is important that the young person at the centre needs to take ownership of their own self management if they are to make a long term recovery, intense care giving from parents may be required for prolonged periods of time. The parents themselves may well need support to do this.

Practical steps

Disconnect within NHS services

Young people may gain benefit from being helped to view recovery in small practical increments. Being able to take tangible steps and to tick off ‘achievements’ helps them to externalise their condition, rather than seeing it as a part of themselves and personality.

“The NHS services don’t talk to each other ... that was a massive problem ... it was worse for my parents ... it was always them that ended up being the communicator between CAMHS and the GP.”

Generation gap Young people can feel misunderstood and sometimes even patronised by medical professionals, and other adult figures of authority rom whom they receive advice and support. This does not necessarily mean that they won’t appreciate and take on board this advice, but obviously has a negative impact on their response to offered support.

Different NHS services do not talk to each other effectively enough. The onus is placed on the user or their parents to fill gaps in information transfer and take control of their care. This causes extra stress to people already in a vulnerable state, and can lead to a variety of problems and misinformation.

See page 90 for further discussion of the intergenerational gap in attitudes to digital and social media

2.2.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM JENNY. Hospital visits and social isolation

Relative nature of wellbeing

Whole person support

Importance of spatial design

“I lost touch with most people at school when I was in hospital for a long time. That was before Facebook.”

“I did get really unwell at Uni, but at the same time I was OK ... like I might have got quite physically unwell, really low weight, but I was doing something that I enjoyed, so I was OK.”

“You’re treating illness, but there is a whole person attached that.”

“There were pictures up on the walls in the waiting room, pictures drawn by kids. The one that always sticks in my head was picture of a gun, picture of a knife, picture of mum and dad and it said ‘Home at Christmas’. And I’m like ... take it down, take it down!”

It is difficult for young people admitted to hospital for acute mental health care to keep in touch with friends. This can be damaging to their recovery in long run. During long hopsital stays, fellow patients become the centre of their social life, which can deny a sense of normality. However, Jenny mentioned that Facebook was helpful in this repsect; in later, shorter hospital visits when she was using Facebook regularly and had strong network of friends online, she was able to keep in touch. This was particularly valuable at night if unable to sleep; friends would often be online and available to chat.

Wellbeing is not only dependent on the level of seriousness of a young person’s mental health condition. How effectively they are able to self manage their condition, how supported they feel in doing so, previous experiences of mental health problems and the state of their home, working and social lives are key factors. Someone suffering from a relatively mild mental health problems may have a lower sense of wellbeing depending on these factors than someone with a more severe condition.

Care should not be illness / service centred. Recovery is only really possible if the young person’s life - aside from their illness - is in positive shape. It is vital that they are helped lead active and healthy social and working lives, and to have focus and purpose away from their illness and services. By placing primary focus on a young person’s illness, rather than on the young person as a whole, can create the sense that their condition in some way defines who they are.

The design of a space - both offline and online - affects the emotional state of the user. Waiting and consulting rooms can be places that inspire or sustain anxiety in patients. An attention to detail is important; Jenny vividly remembers finding the graphic illness posters in waiting rooms unsettling before appointments. Effort needs to be put into creating a positive and calming care giving environment.

2.2.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM JENNY. Trusted figures

Sustained support

Urgency and acute distress

“I don’t like social workers ... I just don’t! ... If its a NHS thing or its got an NHS badge, that might turn me off as well, because I’m already involved with the NHS so much.”

“Something that really helped after coming out of hospital a few years ago was having a nurse I could always contact, and they’d get back to you in 24 hours ... I haven’t used it that much but just knowing that it is there is good.”

“Even a day is a long time when you are contemplating killing yourself. Even an hour is a long time.”

Who young people feel that they can trust for sound advice and support with mental health issues will vary on individual basis. It is important to recognise that what might work for some young people may not for others. Some may build up negative associations with NHS services and other authority figures. In this case, lateral thinking is needed to enable a varied system of trusted and well informed figures, who are in turn supported to be able to provide effective aid.

For young people dealing with mental health problems, having a named professional (such as a support nurse) that they can contact at any time, and receive a response from within a relatively short and clearly determined timeline is extremely valuable. Even if the young person rarely makes contact, if at all, the thought that someone is always there is very reassuring and provides a safety net. It is important that support feels sustained, rather than being made up soley of individual appointments with NHS services.

A fast response time is absolutely crucial when dealing with young people in acute distress. Bureaucracy should not cause of any delay in support.

2.3 CASE STUDY: LISA, 22 Digital Life Lisa recently secured part time employment after graduating from University the previous year, which has allowed her to move out of her parents’ house and into a shared flat. She has been diagnosed and treated for depression and anxiety.

“I CAN TELL THAT MY MENTAL STATE ISN’T AT ITS BEST IF I START SPENDING TOO MUCH TIME BROWSING ON FACEBOOK.”

Lisa’s main connection to the internet is through her laptop. When she is at home, she will have this on almost constantly, even if just to listen to music. There is no television in the house, and her and her flatmate will use their laptops to watch films and videos. She has a mobile phone, but it is not a smart phone. She is very slow at replying to text messages and prefers to make phone calls to friends and family.

vacancies. She is currently employed part time as shop assistant and looking for a job that relates to her degree. She checks the same sites each day. When she finds the search for employment stressful she will often distract herself for long periods of time using social media sites. On realising how much time she has spent on these sites when she was supposed to be searching for work, however, she starts to feel guilty and her stress levels increase.

She has a Facebook account and checks it regularly throughout the day. If her laptop is on, she will normally leave a window open on her Facebook news feed. She has Twitter account (in order to follow her favourite celebrities) but doesn’t post from it much. She also has Tumblr account, and enjoys browsing and collect interesting photos, images and quotes; she will often spend an hour or so at a time doing so. She uses Spotify and Youtube to listen to music at all hours and likes to spend time compiling playlists.

When living with depression, she began to become socially isolated. As she did so, she would spend long periods of time checking and browsing her Facebook wall, but would post very little, messaging friends only if they wrote to her first. This became addictive and gave her the illusion of keeping in touch with friends, despite not socialising very much offline. Eventually, she realised that this behaviour was contributing to her unhappiness. She began to make an effort to socialise offline more, and to use her Facebook account in a more active way, sending messages to friends and instigating ‘chats’ rather than waiting to be spoken to.

Her main internet use aside from this is to search sites for job

2.3 CASE STUDY: LISA, 22 “I WAS ALWAYS AFRAID OF GOING TO THE DOCTOR IN CASE THEY TOLD ME SOMETHING WAS REALLY WRONG WITH ME.” Mental Wellbeing Lisa’s mental health difficulties began whilst at high school, but she was able to self manage to an extent and didn’t have a diagnosed ‘problem’ or condition, nor did she seek any support. She studied intensely and obsessively, to the detriment of her social life. She found it difficult to manage her work load and to maintain a healthy work-life balance, leading her to work late into the night most weekdays and throughout

the weekend. She also exercised obsessively and was very conscious of what she ate, tackling feelings of guilt and anxiety if she ate anything she deemed as unhealthy. However, she was physically healthy and not underweight. She was aware of a general feeling of underlying unhappiness, and was restless to leave school and home. Upon leaving home for university, Lisa began to enjoy a far more active social life and maintain a healthier work balance. She built a large group of friends and was well liked. However, she found romantic relationships extremely difficult and developed intimacy anxieties. This was not something, however, that she thought to seek help for despite it weighing on her mind. She felt unable to admit these worries to anyone. As she reached her third year at university, Lisa once more started to feel unable to cope with the increasing work load. She began to withdraw socially and would spend long hours attempting to work, but feeling physically incapable. This lead to a cycle of long periods of frustrated inaction and listlessness, followed by bursts of frantic activity.

She felt unable to enjoy anything and her usual energy was lacking. She became worried that something was wrong with her physical health. However, she remained outwardly cheerful around others, and her condition went unnoticed until she spent a few weeks with her parents. Having suffered depression himself and without the social facade, her father recognised the signs and after a heated argument, recommended she go to a GP. Lisa’s instant reaction was to rebel against this. She became more determined than before that she could work through any difficulties alone. It wasn’t until after the pressure of a missed work deadline that “something inside broke.” She eventually made an appointment with her GP after constant prompting and reassuring from her mother. She was diagnosed with depression and given medication. She responded well to the medication and felt able to stop using it after six months or so. She felt healthy again, until a few months after graduation. She had been unable to find a job and had to move back into her parents home. She became extremely

socially isolated, spending all day alone in the house and very rarely going out in the evenings. Her confidence wained after every rejected job application. She felt trapped and fell back into a state of depression, which then led to anxiety. She began having panic attacks, which built up until she was, at one point, experiencing them on a daily basis. She managed to partially control them through breathing techniques and in that way kept her state hidden from her family. At first she didn’t understand what was happening to her and became convinced there was something wrong with her heart. Conversely, this deterred her from seeing her GP, as she was terrified she would be diagnosed with a serious illness. This decision not to seek help was then strengthened after self-diagnosing through the NHS website and online forums as suffering from panic attacks; after believing she had a heart problem this came as a relief: “they were just panic attacks! That was fine, I could handle that.”

2.3 CASE STUDY: LISA, 22

“I SHOULD HAVE MADE THAT COUNSELLING APPOINTMENT. THE MEDICATION JUST MADE ME FEEL I COULD HANDLE THINGS ALONE.”

Whilst the medication she has received for both depression and anxiety has been effective, Lisa feels it may have played a part in preventing her from confronting some underlying emotional issues. Whilst she feels her mental wellbeing and self-management skills have gradually progressed despite set backs, she remains in two minds whether to seek counselling.

After making the decision to leave her parents house and live with a friend, Lisa became less socially isolated and managed to find part time work in a shop. The panic attacks receeded and stopped, and Lisa was able to find her own flat. However, after a few months, her work hours reduced and she found it difficult to afford to live. She began experiencing panic attacks again, and they once more built up to be daily occurrences. It was only once a friend admitted to her that she suffered panic attacks that Lisa felt able to talk to anyone about what she was going through. She booked an appointment with her GP and was prescribed medication. She was also advised to self refer herself for counselling, which she did immediately. A couple of weeks later she received an assesment phone call and was placed on a waiting list. She was told a letter would arrive that would notify her when she could make an appointment. By the time this letter eventually came, however she felt much stronger emotionally. Medication had stopped the panic attacks and money problems had eased. She had a two week deadline to make the appointment and decided not to.

She gradually came off the medication and felt healthier than ever. However, she began to feel low again after a relationship difficulty. This was not as serious a low as she had experienced in the past, but she realised that there were underlying issues that she had not addressed and regretted not having made the counselling appointment. Now that she is feeling relatively healthy, she is wrestling with the idea. She fears “opening up” but is aware that it may help her in the long run. She is currently feeling extremely well supported by friends and family, however, which is causing her to question the need to go.

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2.3.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM LISA. Rise of the personal device

Social media and the arts

Social media and deferral

Social media and social isolation

“We don’t have a TV in the flat, so our laptops are pretty much on all the time when we’re home so we can listen to music, the radio and watch DVDs or stuff on YouTube ... There’s a few podcasts and shows that I listen to regularly for news, but mainly the news I get, and things I decide to read or watch are what other people post links to on Facebook. Or show me on YouTube.”

“One of my favourite things to do is to trawl the internet for really interesting photos and illustrations. Sometimes I share links to them on Facebook, but I mainly collect them on my Tumblr and save the .jpgs in a folder so I can look through them when I need a bit of a break.”

“Sometimes, even though I should of been looking for a job, I would find myself spending ages procrastinating online; just scrolling Facebook and Tumblr, reading blog articles and watching stuff on YouTube. Its weird, I knew I was wasting so much time and looking at complete rubbish, but it was like I couldn’t stop and bring myself to do what I should have been doing.”

“I got into bad habits when I moved back in with my parents. I was hardly going out and doing any real socialising at all, just talking to people on Facebook and reading their posts. The less I saw people, the less I wanted to, or the less I felt like I could.”

News, information, entertainment and digital content in general are being increasingly consumed in ways tailored by the individual. Television, radio, magazines, newspapers: all have reduced levels of control in terms of information curation. Young people are used to gathering content from wide variety of unofficial sources; most frequently via one another through shared links and social media posts.

Social media use is not restricted to talking to others. It is also important in the wide dissemination of the arts; of music, film, photography etc. Special interest groups flourish on social media platforms. This may be very important in regards to mental health as a means to aid self realisation and development. Artistic content may also be used as a more imaginative and pervasive means of spreading information and enabling empathy. See page 99 for further evidenced discussion of creativity in relation to digital media.

Young people use social media as means of distraction. This can be innocuous and part of normal teenage behaviour; they may spend long hours on social media sites rather than facing the responsibilities of homework, for example. However, this can enter more serious territory if feeding into the listlessness and inability to perform even simple daily tasks that can be a part of depression.

Socialising online can be an important lifeline for otherwise socially isolated individuals. However, if this remains a young person’s only form of social interaction for long periods of time and begins to entirely replace physical social interaction, it can be damaging and prolong periods of reclusiveness.

2.3.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM LISA. Social media use patterns

“I can tell that my mental state isn’t at it’s best if I start spending too much time browsing on Facebook ... like, just scrolling through my Facebook news feed without actually commenting on anything or posting anything myself.”

Ways in which young people use social media vary greatly. We have previously discussed two broad use catergories - that of active and passive users - but it is far more nuanced than this. What is important, however, is not so much to attempt to catergorise and explain different types of social media use, but instead to recognise that a change in a young person’s use pattern will more than likely indicate a change in state of mind. This can be translated to being an important indicator and point of discussion in monitoring an individuals mental wellbeing and emotional state.

2.3.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM LISA. At risk groups

Emotional barriers to support

Support beyond medication

Self referral

“I guess my problems started quite early on in high school. I was working too much and not socialising too much ... I was also pretty anxious about what I ate and how much exercise I was doing. But no one really noticed, or thought it was actually a big problem.”

“I didn’t want to tell anyone how bad I was feeling. I’m always pretty cheerful and in control when I’m with my friends ... I didn’t want it to seem like there was something wrong with me ... I guess I like seeming like I’m the strong one and that nothing gets to me.”

“It really helped at the time I felt much better ... the medication just made me feel I could handle things on my own. But a little after I came off them I started to feel bad again, because I hadn’t really dealt with any of my issues.”

“It took a lot of building up for me to ring up for a counselling appointment .... the letter took so long to come that by time I felt better, so I didn’t ever book an appointment. I wish I had now, I think I still need it, but I don’t know if I’ll build up to it again.”

Young people at risk of developing mental health difficulties often go unnoticed until diagnosable signs do begin to appear. Early intervention, through the promotion and teaching of emotional literacy and self awareness on a universal basis could prevent some problems from escalating.

Help seeking by young people can be affected by a range of emotional barriers, such as pride, fear and guilt. Similar barriers affect their responsiveness to any support they do receive. Stigma and self-stigma are also factors.

Treatment of mental illness through medication alone is not really enough. For long term wellbeing, emotional, whole person support is needed in addition to the treatment of the physical side of the disease, for conditions of all levels of severity; not simply the most acute or long term.

Placing onus on vulnerable young people to self refer to counselling means that many users may be falling out of service provision before they should. It is difficult for young people in a vulnerable and emotionally volatile state to effectively self manage without prompts, and know what is best for themselves in long term.

2.3.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM LISA. Recovery as a non-linear process

Physical symptoms

Self Diagnosis

Emotional openess in social networks

“After I stopped taking the medication for anxiety I felt so much better. My life was much more sorted and back to normal. I thought that was it, but then a few monthes later I had a really low period again, it kind of took me by surprise.”

“It was having the panic attacks start again that made me go to the doctors. I was just having them so often, and even if I felt OK on a conscious level and wasn’t actually actively worrying about stuff, it was like my body couldn’t help itself. It was scary not having control.”

“I’m much better at just going now, but I was always terrified of going to the doctor in case they told me there was something really wrong with me. I always Googled my symptoms first to try and convince myself that I didn’t have some horrible disease!”

“I didn’t tell anyone I was having panic attacks until my friend told me that she had started having them recently. That made it easy to tell her ... then after that I told my mum and a few other friends ... it was much easier to deal with then.”

Recovery should never be explained in terms of a quick fix, or of a black and white distinction between ‘ill’ and ‘well’. Young people need to be prepared for set backs and possibility of relapse, but with an emphasis on gradual progress.

Many young people will often not seek or be given support until the physical manifestations or consequences of mental ill health begin overwhelm them, or become obvious to others.

There has been much recent discussion on the topic of self diagnosis via the internet and it is clear that it can have negative effects. In some cases, self diagnosis may help to prevent young people from seeking and coming into contact with support services, instead attempting to tackle problems alone when aren’t fully capable. However, it must be recognised that self diagnosis in this way is common; advice and support to self manage beyond this must be just as readily available.

Openness and honest conversations with friends and family are key to emotional wellbeing. For young people reluctant to seek support, hearing the honest discussion of experiences of mental health from people within their immediate social network can give them the courage or push they need in order to do so, or at least to voice their difficulties.

See page 107 for futher evidenced discussion.

2.4 CASE STUDY: BEN, 16 Digital Life

“MY THREE BEST FRIENDS LIVE IN DIFFERENT PARTS OF THE COUNTRY, BUT WE SPEND EVERY EVENING GAMING AND TALKING ON XBOX LIVE. WE MIGHT AS WELL BE IN THE SAME ROOM.”

Ben is at high school and lives with his parents and brothers. He has no mental health problems of his own to speak of, but often finds himself acting as support for friends who do. He is extremely comfortable with digital technology. Online activities play an important and active part in his social life.

Ben has just acquired his first smart phone (thanks to his mum receiving an upgrade on her own phone), but his main access to the internet comes through his Xbox and laptop.

a separate console.

Ben’s Facebook use does not stretch much beyond sending game “cheats” to his closest friends and “having banter” with them and his mum. He also uses it to send In terms of social media use, Xbox private messages to his female Live is to him the most important friends, with whom he says he and is key to his social life. communicates quite differently; Circumstance and the fact that his he is more likely to discuss more family have lived in a couple of emotional issues at length via different parts of the country mean private messaging or on the phone. that his three closest friends live at quite a distance from him. Unable to Although Facebook is blocked at school, he and a few of his friends meet physically, they spend almost have found ways to trick the system every evening playing Xbox games in allowing them access; he is an online together, simultaneously adept user of technology. communicating on other forms of social media. He does not have a Twitter account and the only other social media site After sending each other extremely he could say he has used is AskFm. brief texts alerting them to “go He joined because “everyone at online”, they will play a game school was on it” but stopped using together on Xbox Live, utilising the it after a week. He was unable microphone “chat” option at the to “see the point of it” and was same time (essentially a prolonged disgusted by the bullying nature four way Skype call). They will also of most of the comments. He is send each other links to YouTube confused by the behaviour of many videos, images and game “cheats” of his school friends, who complain on Facebook, which Ben will have open on his laptop. This is all done constantly about the site - often on Facebook - yet continue to use it. in the same room as his brother, who will also be playing games on

2.4 CASE STUDY: BEN, 16 Mental Wellbeing Ben has no mental health issues of his own to speak of. He is extremely talkative and able to seems able to express himself freely, without the embarrassment or introversion that can be common in teenage males. He has a strong, healthy relationship with his mother, to whom he feels able to talk to about most things and to go to for advice. He is compassionate and caring, and often finds himself supporting others through difficulties, some quite serious. Within his group of friends, one struggles with bi-polar disorder, another with bulimia and self-harm. Two of his closest friends have quite recently lost parents, and another is a young carer with a heavy responsibility to bear at home. Although demonstrating an awareness and understanding of mental illness, he didn’t make an easy and instant connection between the problems his friends were facing and mental health issues. He was unsure that bulimia “counted” as a mental health problem and didn’t think to seek support or advice when consoling

his friends, despite often feeling unsure what best to do or say. He would often, however, discuss matters with his mother, even ringing her at the time in one case of particular urgency. The supporting role that Ben provides to his friends has not had a damaging effect on his own mental health and he maintains a very positive outlook. He is thoughtful, and demonstrated an ability to discuss the issue of mental wellbeing in an extremely mature and insightful manner. He is particularly concerned that his female friends place far too much value in their appearance; for him “advertising is to blame ... and celebrities”. This concern extends into their Facebook use; he hates to see his friends posting so many “selfies” and wearing excessive amounts of make up. He is keen that everyone should be confident and happy to be an ‘individual’ and that this confidence would help people to treat each other better.

“ONE OF MY FRIENDS HAS BULIMIA. DOES THAT COUNT, IS THAT A MENTAL HEALTH PROBLEM?” Ben often finds himself consoling friends or trying to help them through quite serious problems. He doesn’t instinctively consider this as supporting them with mental health issues though. Despite sometimes not feeling like he knows what best to say and do on these occassions, he doesn’t think to seek formal advice or support for his friends. In some situations he will ask his mother for advice, but this is not always the case.

3RD SECTOR SUPPORT GROUPS

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BENʼS CONTACT WITH SERVICES.

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Services user has come into contact with for mental health support.

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2.4.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM BEN. Long distance friendships

Gender differences

Technical expertise

“I’ve lived in a few different places, so my three best friends live in different parts of the country, but we spend every evening gaming and talking on Xbox Live. We might as well be in the same room. We talk on the Xbox mics and we send each other YouTube links on Facebook to stuff we are talking about ...”

“My girl friends often message me to talk about more emotional stuff, but the guys don’t. Its all just banter with the lads.”

“Yeah, Facebook is blocked on the school computers, but me and my mate have found a way of getting round it. We’re the only ones that know how to do it.”

Young people’s use of social media allows for long distance friendships to be maintained in active and frequent ways; friends living in different places can engage in the same game, talk to multiple people simultaneously and see each other in real time, almost creating the illusion that they are in the same room. They are, in fact, sharing the same space. Sites such as Facebook also have the positive effect of allowing disparate users to keep in touch in more passive way via

shared updates, and to have brief, yet meaningful interactions and conversations that wouldn’t otherwise happen. Young people are also able to converse with and befriend strangers on the basis of shared interests and views rather than geographical circumstance. Online socialising can take up as much or more even time as offline meet ups. The key to wellbeing is a balance of both.

Young women are seemingly more able to discuss emotions and admit distress; both to each other, and to male friends on an individual basis. Young men are often less able to, or unwilling to, express themselves as easily and freely. Peer support amongst young men takes a different form. They are often aware of each others problems, but their main supportive interactions tend to centre around jokes and shared deferral activities. Of course, this is not always the case and gender cannot be defined in such simple terms. Crucially though, this is the way in which most young people themselves perceive gender differences in communication, and hence can feed into an enactment of these roles. Differences do seem to generally reduce with maturity.

Many young people, as digital natives, are very knowledgable and creative internet users. Some are able to find their way around blocks and filters, and to create their own digital content of varying degrees of sophistication.

2.4.1 CASE STUDY INSIGHTS: DIGITAL LIFE - LEARNINGS FROM BEN. Attraction to risk

Social media and narcissism

“I just don’t get why people still use AskFm. They use it, get a load of abuse, complain about it in their Facebook status, and then carry on using it!”

“Some of the girls at school just take so many selfies and put them on Facebook ... they’ll always be wearing loads of makeup and sometimes they comment on it with stuff like “feel so ugly today.” I hate it, I hate that people put so much importance on how they look. It’s advertising’s fault I think.”

It is common for teenagers to experiment with risk and to be attracted to activities and behaviours that they know to be potentially dangerous or damaging to their wellbeing. This is also the case online; AskFm providing a key example. There seems to have been a morbid fascination with the site amongst young people, despite (or perhaps because of ) its negative reputation and users frequently becoming victims of abuse and bullying.

Social media profiles allow young people to construct identity in a different and controlled, ‘editable’ way. Social media sites are by and large user profile centred, which can encourage narcissistic behaviours; young people are very conscious of shaping how they are perceived through their Facebook walls and their Twitter streams. Whilst it can be beneficial to have a good awareness of self, and social media could be seen to help with self realisation in this sense, there are some downsides. Self realisation needs to be conscious, which is

arguably not quite the case in the ways in which most young people are shaping their online personas; the emphasis is on how they will be perceived by others within their social network, rather than on true individual expression. Social media sites invite and cause young people to constantly present their lives as series of events, achievements and photographable moments and to compare themselves to others through these. See page 99 for further discussion on identity in relation to social media.

2.4.2 CASE STUDY INSIGHTS: MENTAL WELLBEING - LEARNINGS FROM BEN. Peer support

“One of my friend’s girlfriends self harms ... she’s had a difficult time since her mum died. I try to help out, but its hard to know what to say. I just try and listen.”

Most young people - who may not be experiencing mental health problems of their own - are acting in some way or another as a means of support for those who are, often without fully realising that this is what they are doing. Despite sometimes feeling unsure of what best to do and say in order to help, few seek any kind of formal advice. Issues of trust may mean that these young people feel obliged to keep friend’s problems secret, despite this perhaps not be in their best interest.

Importance of parental figures

“My mum is great, I can tell her pretty much anything. She is the first person I talk to about stuff.”

All young people need an adult who they trust for good advice, go to for support and who will look out for their welbeing. A parental figure doesn’t necessarily have to be a parent specifically, and indeed is beneficial to young people to have an adult that they trust outside of family circle and all the emotional barriers this can entail.

Celebrating emotional intelligence Emotional intelligence is often under appreciated in schools and beyond. It needs to be celebrated and encouraged in same way as intellectual, artistic and sporting abilities and achievements. We should be nurturing those young people with natural emotional intelligence and compassion for others, and encouraging emotional learning in all young people. Most are very capable of discussing difficult and emotional issues in mature fashion when in the right environment and challenged and helped to do so.

Equally, it cannot be overlooked that there will be minority young people who abuse the trust of others using disclosed information to the detriment of friend’s who have told them things in confidence.

FINDINGS CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 3 INSIGHTS THROUGH YOUTH ENGAGEMENT THIS SECTION DETAILS THE KEY INSIGHTS THAT EMERGED THROUGH OUR ENGAGEMENT AND CO-DESIGN SESSIONS WITH YOUNG PEOPLE.

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

CHAPTER 4 OUTCOMES OF CO-DESIGN SESSIONS

CHAPTER 5 DESK RESEARCH FINDINGS

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

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INSIGHTS THROUGH YOUTH ENGAGEMENT This chapter details key insights derived from the five initial engagement sessions. They are presented in the following three broad categories, with some overlap: 3.1. Insights relating to digital media use in young people. 3.2. Insights relating to youth mental health and attitudes. 3.3. Insights relating to digital media use by young people specifically in relation to mental health. They are supported by the case study interview findings and the reader will notice considerable overlap. All quotations in this section are from engagement group participants and have been kept anonymous.

3.1. INSIGHTS: DIGITAL MEDIA USE IN YOUNG PEOPLE 3.1.1 Perceived importance of digital & social media and frequency of use. Digital and social media use is pervasive and a central part of the daily lives of the majority of young people. Most can’t imagine life without their mobile phone and internet access in general. The loss or breakage of a mobile phone creates frustration and disruption to the smooth running of their family and social life. Social media sites - Facebook in particular - are so integrated into the fabric of a young person’s social life that they are not really regarded as being separate from their offline world. Many young people claimed to be permanently connected to sites such as Facebook and Twitter through their smart phones even whilst in school. They would not always be actively engaged, but would be ready to check their accounts immediately upon receiving notifications and messages. Facebook in particular is used not only as a social space in its own right, but as a means to organise offline events, parties, meet ups and even phone calls. Social media use plays an important part in the actualisation of a young person’s identity. The contents of their Facebook wall, their choice of ‘profile picture’, comments and posts made to others and (crucially for some young people, despite not always wanting to admit that this is the case) the number of ‘friends’ they have, plays a part in the way in which they are perceived, also in an offline context. A few young people even admitted to writing ‘fake posts’, claiming to be socialising when they weren’t in order to “seem more interesting”. Whilst young people seemed to view their digital and perhaps more controlled representation of identity as one and the same as their ‘offline self’, on reflection some could identify points of difference which could create slight friction or new dynamics in friendships. In regards to Facbook in particular, the main reason for having an account seemed to be the fact that everyone else did; the fear of missing out is a key motivating factor. Of all the young people we spoke to, only one individual did not have a Facebook account. This was viewed by others in

the group as unusual, and they attempted to encourage him to get one without having clear positive reasons for doing so beyond ‘well, why not?’ His reason for not having an account was also vague, but he put it down to the fact that he had had never one when he was younger, so had simply “not got into the habit” and didn’t feel that he was missing anything.

“MY FRIEND WENT ON HOLIDAY UP NORTH FOR A COUPLE OF WEEKS AND DIDN’T HAVE ANY INTERNET. WAS LIKE HE HAD DISAPPEARED OFF THE EARTH. HE GOT SO BORED BY THE END HE STARTED CALLING US.” Social and digital media use makes up for a large part of a young person’s leisure time. Entire evenings will often be spent gaming, watching videos on YouTube and downloading or streaming films (often in place of watching television), or simply ‘being on Facebook’, chatting and browsing. Even whilst engaging in offline social activities, most young people will remain connected to social media sites through their mobile phone. It is very common to simultaneously publicise any offline activity they may be engaged in through photos, posts and videos.

3.1. INSIGHTS: PERCEIVED IMPORTANCE OF SOCIAL & DIGITAL MEDIA The young people we worked with named social media sites as their main source of news; both in terms of world affairs, ‘celebrity gossip’ and social updates from friends, acquaintances and even family. The internet also seemed to provide their main access to the arts, through the streaming and downloading of films, music, comics and visual art.

TEXTING, HOWEVER, REMAINS IMPORTANT TO YOUNG PEOPLE AS A MEANS OF DIRECT, IMMEDIATE, ONE-TO-ONE COMMUNICATION BETWEEN FRIENDS AND PARENTS ESPECIALLY. The young people we spoke to still used text messaging on a frequent basis. Texts were mostly used to ask specific questions and carry out more personal communications.

Photo by J Devaun under a Creative Commons License

3.1. INSIGHTS: EXCESSIVE USE OF SOCIAL MEDIA 3.1.2 Excessive use of social media. Many of the young people we spoke to admitted to checking their social media accounts and phones compulsively and placed a sense of reliance on being able to do so. For some, this was carried out with such regularity that they would experience withdrawal like symptoms and mild anxiety when they become unable to do so, even for very short periods of time. Some said that they found the experience of being without social media quite freeing or at best managable after the initial withdrawal; others maintained a sense of anxiety or frustration.

WHEN ASKED IF THEY FELT THAT THEY SPENT TOO MUCH TIME ENGAGING WITH SOCIAL MEDIA, MANY YOUNG PEOPLE DEMONSTRATED A CONTRADICTORY STANCE, INITIALLY DENYING OVERUSE OF SOCIAL MEDIA, BUT ON FURTHER QUESTIONING SHOWING VAGUE FEELINGS OF GUILT FOR THE AMOUNT OF TIME SPENT “WASTED”.

Photo by Rachel Johnson under a Creative Commons License

Some social media interactions are designed to encourage extended periods of screen time. Constantly updating newsfeeds and comment streams, ‘infinite scrolling’ functions and hyperlinks to related content encourage prolonged and quite passive consumption of information. The simple sense of satisfaction derived from receiving notifications and messages provides reward for compulsive account checks.

3.1. INSIGHTS: POPULAR DIGITAL & SOCIAL MEDIA 3.1.3 Most popular social media sites

Photograoh by Jason A. Howie, under the creative commons license

Facebook and YouTube were by far most popular social networking sites amongst the young people attending our engagement sessions. As such, they were far more interested and engaged in conversations about Facebook and YouTube than any other social networking sites mentioned. Twitter and Tumblr were also well known, but used by less. Many commented that they ‘didn’t see the point’ of Twitter.

MOST OF THE YOUNG PEOPLE PROFESSED TO USING FACEBOOK VERY HEAVILY. DESPITE THIS, THEY HAD FAR MORE NEGATIVE THINGS TO SAY ABOUT IT. IMPORTANTLY, MOST SEEMED TO ENJOY COMPLAINING ABOUT IT AND THE PERCEIVED NEGATIVES DID NOT DISSUADE THEM FROM USING THE SITE. In comparision Youtube had far less complaints. The biggest downside was seen as the amount of ‘trolling’ that could occur in comment streams. However, this abuse was seen as easier to deal with than if it had occurred on Facebook, as it was deemed less personal and targeted. Many in fact found arguments within YouTube comment streams entertaining.

3.1. INSIGHTS: POPULAR DIGITAL & SOCIAL MEDIA 3.1.4 New and trending social and digital media Besides Facebook and Youtube, there were two other forms of social media that sparked interest and lively discussion in particular; namely the site ‘AskFm’ and the app ‘Snapchat’. Interest came largely due to their respective notoriety (AskFm in particular) and novelty. AskFm is a social media site allowing users to pose any question they choose and to receive answers from other users, all done anonymously. It had achieved notoriety amongst the young people due to the rifeness of abuse found within the answers and escalation of ‘cyberbullying’ as a result. Opinion on the site was mixed. Most young people seemed either appalled or dismissive of the site, not able to understand why others continued to use it. All said however, that had friends that continued to use

the site, but would complain about it; demonstrating a fascination with the site despite - or perhaps because of - the risk of abuse. Snapchat is a mobile phone app that allows users to send images or videos with a text message if desired attached to others. The content will then disappear very quickly after being read or seen. Whilst also having an air of notoriety, the attraction to the app seemed to be largely positive and due to the novelty of this interaction, and the potential of this as a means to share jokes with friends. However, it must be considered that due to the nature of the group sessions, it is unlikely that topics such as ‘sexting’ for which Snapchat has recently earned this notoriety would have been discussed openly.

“I HAD AN ASKFM ACCOUNT FOR ABOUT A WEEK BECAUSE EVERYONE AT SCHOOL HAD ONE, BUT I DELETED IT. I DIDN’T REALLY GET IT AND IT WAS JUST FULL OF ABUSE. SOME OF THE PEOPLE IN MY CLASS STILL HAVE IT, BUT I DON’T UNDERSTAND WHY. THEY’RE ALWAYS JUST COMPLAINING LOADS ON FACEBOOK ABOUT WHAT PEOPLE HAVE SAID TO THEM ON IT.”

3.1. INSIGHTS: SOCIAL MEDIA USE PATTERNS 3.1.5 Identifying social media use patterns The young people involved in the engagement groups often talked about social media use as generally falling into two camps, with users being described as either ‘a talker or a stalker’. ‘Talkers’ are active users, who generate and disseminate a lot of content. ‘Stalkers’ are passive users, consuming content created by the ‘talkers’ and generating far less of their own. Individuals fit the categories to varying extent and may shift between them. Use patterns are of course far more complex and nuanced than this and different social media sites afford different behaviours. Individuals will not always have a consistent pattern of use and may go through ‘phases’, which can be telling as to a change in state of mind. This recognition ie. that a change in a young person’s use pattern may indicate a shift in mental state and wellbeing - is perhaps more pertinent to this report than to attempt to categorise and investigate specific patterns of use, especially as social media sites - and the interactions and functions they afford - are constantly changing and being updated.

3.1.6 New behaviours and social etiquettes created by digital media interactions Every new form of digital and social media can be seen to create a slightly different set behaviours and social norms. Most social media sites and forms of digital media - both in terms of hardware and software - are constantly being altered and re-designed, and at an ever increasing pace. Even the smallest changes in interaction can cause subtle shifts in behaviour and new sets of social pressures. One example that came up repeatedly in discussions with young people was a recent change made by Facebook in the nature of their private messaging function. It is now possible to see the exact time at which a message you have sent has been opened by the receiver. This small change has created a new set of anxieties for young people. They feel pressured to reply immediately, often feeling guilty if they do not do so. Equally, they worry if they see that the message has been received but not replied to, beginning to second guess reasons for this.

CHANGES IN A YOUNG PERSON’S PATTERNS OF USE OF SOCIAL MEDIA CAN INDICATE CHANGES IN MENTAL STATE AND WELLBEING.

3.1. INSIGHTS: EXPERIENCES OF SOCIAL MEDIA SITES 3.1.7 Positive vs negative experiences of social media sites

Perceived positive aspects of Facebook:

As mentioned previously, discussions of social media centred on Facebook almost without fail, and the young people seemed to enjoy complaining about it in particular. Internet trends are fast moving and coming years may well see a shift away from such heavy use of Facebook, but for the young people in our engagement sessions it remained the most important and most used form of social media. As such, this section will concentrate primarily on the young people’s experiences of Facebook use.

It constitutes a rapid source of news for young people. The majority of young people claimed that they “find out what is going on in the world” through the statuses and posted links of others within their network. They also greatly enjoyed the possibility of keeping track of gossip, sometimes in relation to celebrities, but primarily to friends and acquaintances.

“FACEBOOK IS GREAT! YOU CAN BE REALLY NOSEY WITHOUT OTHERS KNOWING.” It provides a positive way to keep up with friends not seen for a while or talked to on a daily basis. Many said that they wouldn’t be likely to contact such friends without the prompt that Facebook provides. Long distance friendships can also be maintained in more active and frequent ways; friends living in different places can see each others lives unfold in a way, talk to multiple people simultaneously and engage in the same games. They are, in this way, sharing the same space despite distance, especially given the amount of time young people are present online.

It allows young people to converse with and befriend people on the basis of shared interests and views rather than geographical circumstance. Valuable and interesting information and links can be shared with people they are unlikely to ever meet, creating a positive sense of a wider, global community.

3.1. INSIGHTS: EXPERIENCES OF SOCIAL MEDIA SITES Perceived negative aspects of Facebook: Interestingly, perhaps the most common phrase across all the engagement sessions was: “People ruin Facebook”. It was generally agreed that there is nothing really wrong with the site itself - “it is what it is” - but rather in the way in which it is used. The idea that it may afford negative behaviour was not considered by young people.

Targeted advertising was a cause for annoyance and was even mentioned as potentially dangerous in regards to young people suffering from eating disorders, due to prevalence of dieting and exercise adverts. Spam notifications and posts that appear on the home page stream where regarded in similar fashion.

There was an interesting contradiction at the heart of the young people’s Facebook use. Everyone seemed to enjoy seeing (or “spying”, or “creeping” as it was referred to most frequently) what was going on in the lives of their Facebook ‘friends’. This obviously relies on people sharing details of what they were doing and how they were feeling. However, there was a consensus that many people ‘overshare’ or become overly ‘comfortable’ on Facebook, posting material they deemed inappropriate. In particular, those who posted a lot about their feelings (negative feelings especially) were seen as ‘attention seekers’. The threshold for was difficult to define.

Excessive use of social media was a cause for concern to some upon reflection. As discussed previously, the vast majority of the young people in our engagement sessions said that found it very difficult to go without checking Facebook - and without access to the internet in general - for any length of time. Some recognised their dependance on Facebook and the internet in general was cause for concern, and that spending hours at a time online was something to feel guilty about due to the notion that it was a ‘waste of time’.

The practice of ‘fraping’ (gaining access to another’s account and posting or carrying out other interactions in their name without their knowledge) whilst sometimes viewed as entertaining, was largely regarded as becoming “annoying”. There were also stories of difficult situations and arguments caused as a result of malicious ‘frapes’. Such casual adoption of language of sexual violence in this phrase was not raised as a point of discussion by the young people and they seemed to use it without second thought.

“I HAD TO GET MY DAD TO DISCONNECT THE WI-FI WHEN I WAS REVISING FOR MY HIGHERS. I KEPT PROCRASTINATING ON FACEBOOK AND YOUTUBE, I WASN’T GETTING ANY WORK DONE.” 57

3.1. INSIGHTS: EXPERIENCES OF SOCIAL MEDIA SITES Perceived negative aspects of Facebook (continued): ‘Unfriending’ someone is perceived as something of huge significance and as difficult to deal with (especially in relation to ex boyfriends or girlfriends). Where as offline it is often possible to simply avoid someone you wish to stop seeing for whatever reason, it is more difficult on Facebook. The same applied to accepting or making friends requests (again, most often in relation to romantic interest).

‘Friend collecting’ (the practice of becoming Facebook friends with as many people as possible, despite hardly knowing many of them, in order to “seem popular”) was seen as very common, but regarded in a negative light. None of the young people admitted to exhibiting this behaviour themselves, but could name friends that they regarded as being guilty of this.

Cyberbullying was named as a major downside and seen as quite common. As with ‘offline’ bullying it takes many different forms. We heard examples of continued abusive comments being made publically or in private message form. One young person also feared that a bully used Facebook as a means of finding out her whereabouts at a given time.

“THERE WAS THIS HORRIBLE VIDEO GOING ROUND FACEBOOK OF A MAN IN MEXICO BEING BEHEADED. THE LINK THAT PEOPLE WERE POSTING HAD A DIFFERENT THUMBNAIL IMAGE AND TITLE, SO YOU DIDN’T KNOW WHAT IT WAS ABOUT STRAIGHT AWAY. I CLICKED ON IT, AND IT WAS JUST TRAUMATISING. I WISH I HADN’T SEEN IT. I WOULD NEVER HAVE LOOKED FOR SOMETHING LIKE THAT.” The accidental exposure to videos/images/links of a disturbing nature was a cause for concern. Many said they had clicked on a seemingly innocuous link that appeared in their stream only to find it took them to something “horrible” and inappropriate that wouldn’t have actively searched for.

3.1. INSIGHTS: SOCIAL CAPITAL & GENDER 3.1.8 Social capital and inclusion in relation to social media sites

5.1.9 Gender differences in digital & social media use

Social networks can be seen to contain key social influencers. These users will be vocal, have a large amount of ‘followers’ or ‘friends’ and will therefore have the widest reach in anything they post or share.

Differences in male and female interactions with social and digital media, and in communicating in general were noted by the young people. For our engagement group participants, young women are seemingly more able to discuss and express their emotions and admit distress; both to each other, and to male friends on an individual basis. They would often be seen to use Facebook in order to do so. They were more likely to use lengthy private messages in order to do this, or to send text messages. Young men were seen as less able to, or unwilling to, express themselves as easily and freely and peer support amongst young men takes a different form. They are often aware of each others problems, but their main supportive interactions tend to centre around jokes, making light of the situation and shared deferral activities. Initially, many discussions on gender differences would begin with the assertion from many that young men are simply not as emotional as young women, and that expressing emotion freely was a sign of weakness and lack of masculinity. When caused to reflect on this, however, most would begin to question the truth of this.

When discussing with young people the often very regimented social structure within schools, we did see some difference in this online. We were told stories of young people deemed to have less social capital having the confidence to speak to groups or individuals outside of their normal social group online, in a way that wouldn’t happen school. However, this online confidence was not generally seen to subsequently translate back into the school environment. It is difficult to conclude much in terms of social isolation as it was not something that the young people taking part in the engagement groups felt applied to them (or were willing to admit was the case.) There was one sensitive discussion, however, with an individual who considered himself quite socially isolated. He didn’t view Facebook (the only networking site he used) as aiding his social life in this respect, as he only really used it to talk to cousins living abroad and to read updates from others without engaging. Instead, he received support through an after school group made up of students from mixtures of years and classes.

Of course, this is not always the case and gender cannot be defined in such simple terms. Crucially though, this is the way in which most young people themselves perceive gender differences in communication, and hence this fuels the enactment of these roles.

“THIS BOY I NEVER SPEAK TO AT SCHOOL ADDED ME ON FACEBOOK AND STARTED COMMENTING ON MY POSTS AND ‘LIKING’ STUFF. BUT HE STILL DOESN’T SPEAK TO ME AT SCHOOL, HE JUST KIND OF LOOKS DOWN WHEN I WALK PAST.” 59

3.1. INSIGHTS: GAMING 3.1.10 Gaming Photograoh by ‘The World According to Marty’, under the creative commons license

Digital gaming was seen as a key leisure activity, particularly by young men. There were distinctions made between social and individual gaming. Many young men would spend long hours playing together, either in the same room or in an online space, utilising networked consoles (X-box Live was the key example.) Individual gaming was generally discussed in terms of addiction or ‘procrastination’. The game ‘Candy Crush’ (a multiple level, sweet themed logic game) was mentioned frequently in this respect, described as being annoyingly addictive; many said that they or their friends would often disengage from conversations and social situations in order to play the game on their phone.

“A COUPLE OF MY FRIENDS ARE JUST OBSESSED WITH CANDY CRUSH. WE’LL BE SITTING HAVING A CONVERSATION AND THEY’LL JUST BE LOOKING DOWN AT THEIR PHONE ALL THE TIME PLAYING IT. THEY GET REALLY ANNOYED WHEN THEY CAN’T COMPLETE A LEVEL TOO.”

3.1. INSIGHTS: ONLINE RISK MANAGEMENT 3.1.11 Attitudes to privacy in relation to social media use There were mixed reactions to the theme of online privacy. It was important to some to ensure that their social media use could only be seen by those within their network, but more or less irrelevant to others. Each seemed to have their own self constructed boundaries, choosing on a largely subconscious level what they were willing to post and to whom. Deliberate choices were made to communicate with friends through private messaging services or text messages when wishing to discuss more personal information. Annoyance was expressed at those who didn’t seem to have any boundaries (although this is unlikely) as to what they would post; it was seen inappropriate and ‘attention seeking’ to share absolutely everything in a public digital space.

“I HATE IT WHEN PEOPLE SHARE EVERY DETAIL OF THEIR LIVES ON FACEBOOK. SOME PEOPLE JUST DON’T SEEM TO KNOW WHAT IS TOO MUCH INFORMATION: I DON’T CARE WHAT THEY ATE FOR BREAKFAST OR HOW MUCH THEY LOVE THEIR BOYFRIEND FOR LIKE THE FIFTIETH TIME.”

“YEAH, YOU GET SOME CREEPS ONLINE THAT TRY TO TALK TO YOU AND FRIEND YOU. ONE OF MY BEST FRIENDS SEEMS TO BE A MAGNET FOR IT. BUT ITS EASY TO DEAL WITH, YOU JUST BLOCK THEM.” 3.1.12 Self regulation and management of risk by young people The young people demonstrated an ability to deal with negative internet use and safeguard against risk. They discussed tactics for spotting ‘creeps’, as they were referred to, and how to “deal with them”. Many looked out for their friends in this regard. Some also had techniques in place for ignoring or shaming bullies, and some of those with mental health problems made use of means by which to avoid triggering content. Having techniques in place did not necessarily mean, however, that they would always be employed. Vulnerable individuals can be seen to lapse on self managing behaviours and cyberbullying and online abuse was considered difficult to deal with.

3.1. INSIGHTS: BARRIERS TO MEDIA USE / BLURRING OF SOCIAL SPACES 3.1.13 Technical/physical barriers to digital and social media use

3.1.14 Blurring of social spaces through social and digital media

Although everyone we spoke to possessed their own mobile phone, not everyone had smart phones. Those that did would often not be able to afford large amounts of roaming time and would have a low download limit, reducing the extent to which they would access the internet on their phones, beyond the ubiquitous use of the Facebook (and sometimes also Twitter) app.

Through Facebook in particular, the different components of a young person’s social network that would normally remain more or less separate are becoming increasingly mixed. In a single digital space, young people will be communicating publically (either directly or indirectly) and simultaneously with: family members; school, college or university friends and acquaintances of different ages and social circles; work colleague; friends from different cultural, sporting and shared interest groups; neighbours; friends of friends; parents of friends; and complete strangers. The impact this has on identity creation and self realisation needs further examining.

Due to slow buffering, it is not always possible for young people with smart phones to watch videos online and many websites are not in a phone friendly format. There was a considerable number of young people - particularly amongst those still within high school - without their own laptop or tablet computers. Within schools, many forms of social media, including YouTube and Facebook, are blocked. Other online content is subject to strict controls. Young people with 3G coverage on their smart phones are able to get round this. We even heard stories of teachers specifically asking young people to ‘google’ information or watch videos on YouTube for educational purposes during lessons. Learning difficulties can also create barriers to use, especially for text heavy content, although were not seen to prevent enjoyment of Facebook and YouTube in particular amongst the young people with learning difficulties that took part in our engagement sessions.

“MOST OF MY FACEBOOK FRIENDS ARE FROM SCHOOL, BUT I’VE GOT THE LADS FROM THE FOOTBALL TEAM AS WELL AND PEOPLE ON MY STREET AND AROUND. MY MUM IS ON FACEBOOK AND MY UNCLES, BUT MY DAD HATES IT. SOME OF MY FRIENDS’ MUMS HAVE ADDED ME TOO.”

3.2. INSIGHTS: YOUTH MENTAL HEALTH & ATTITUDES 3.2.1 Young people’s perceptions and understanding of mental health The young people’s understanding of mental health was quite clearly illness focused. When asked to brainstorm what mental health meant to them, the first point of discussion always centred around various conditions and the use of slang and derrogatory terms such as “crazy”, “nuts” etc. This illness weighted understanding may have a lot to do with the way mental health is discussed within the school curriculum, with some of the young people speculating as much. Mental health was framed negatively, initially seen by most as something to worry about if you became ill, but not as something that would require positive, daily maintenance in the same way as physical health. This tended not to be the case though amongst young people suffering from a diagnosed mental health problem themselves, or providing official care for someone else. It was common for these young people to demonstrate a high level of knowledge about (and interest in) the symptoms and definitions of various mental illnesses, medications and other treatments, and politically correct terms.

However, sometimes with prompting, sometimes through self direction, all the young people we worked with proved able to discuss mental health with great maturity and in wider terms, talking of emotional wellbeing, difficulties and literacy. Most conversations were insightful, with some individuals displaying very impressive levels of emotional intelligence. Many demonstrated an intuitive ability to look after and manage their own mental health, without thinking about it in particularly conscious manner or in these terms. Techniques for coping with emotional difficulty were discussed and all were aware of the importance of expressing emotions and sharing problems and fears (whether on not they felt able to do so effectively or not.) After initially struggling to think of ways in which positive mental health could be achieved and maintained, an array of practical steps emerged.

“AT SCHOOL WE JUST LEARN A BIT ABOUT WHAT DIFFERENT MENTAL ILLNESSES THERE. WE DON’T EVER REALLY TALK ABOUT HOW TO BE HEALTHY, OR DEALING WITH YOUR EMOTIONS, STUFF LIKE THAT. ”

3.2. INSIGHTS: WHO YOUNG PEOPLE TRUST FOR ADVICE 3.2.2 Who young people trust for advice about mental health related issues Who young people turn to for information and support with mental health issues varies on an individual basis. There was much discussion of parents in this respect. Some claimed to feel comfortable speaking to their parents, or one parent in particular, about any difficulties they faced. This was not dependent on the young person having a positive, supportive relationship with their parents; many who claimed to have otherwise mainly positive and supportive relationships with their parents felt unable to discuss their own mental health issues with them for a variety of reasons. Often cited was a fear of disappointing or worrying parents unduly, and of not wanting to cause them to feel a sense of guilt or parental failure. Some felt that it was simply better to discuss such matters with friends, as they would be better placed to understand and empathise with their problems, and less likely to want to take some form of control of the situation. However, despite the feeling that peers often made for good, sympathetic listeners, there was an awareness that they may not always be best placed to provide sound, experienced advice. Grandparents and older siblings were also mentioned by some as reliable sources of support and advice. Teachers and other such official authority figures were not really mentioned, GPs being the exception. Again, opinion was mixed; whilst some relied on their GP as a key (if sporadic rather than sustained) source of advice and had had positive experiences, others found the idea of visiting a doctor intimidating. A few young people who had seen a doctor for advice had felt patronised and that their concerns were not taken seriously enough. In comparision to physical health, there was less confidence in the ability of a GP to provide effective mental health care. Some young people also mentioned seeking advice through digital assets, including forums and NHS websites, as a less intimidating alternative to medical support. The idea of self help where possible was viewed favourably. Some young people suggested that the reactions of others to disclosed problems can

sometimes make them seem worse than they had done previously, and that the feeling that you are being helped can in itself trigger negative emotions and reactions. The young people who seemed the most self confident and capable of managing difficult emotional situations were those who had a variety of people to whom they could go for advice and support; some of these would be adults and, specifically, a parental figure. A parental figure doesn’t necessarily have to be a parent specifically, and indeed is beneficial to young people to have an adult that they trust outside of family circle and all the emotional barriers this can entail.

3.2.3 Perceived attitudes of adults to young people’s difficulties Some young people we spoke to felt misunderstood and sometimes even patronised by medical professionals and other adult figures of authority from whom they receive advice and support. This does not necessarily mean that they didn’t appreciate and take on board this advice, but can clearly have a negative impact on their response to offered support. Some young people had been upset by careless remarks made by adults that made light of their problems, along the lines of “you need to pull yourself together” or “its not that bad, other people are worse off.” Such negative associations made some reluctant to ask for help from more official sources, and to prefer instead to discuss their problems with peers. Some young people had, however, very positive experiences in this regard. Some had strong bonds with one parent in particular or a favoured teacher or youth group leader. Grandparents were viewed by some, despite the generation gap, as better than parents in being able to empathasise and really take time to listen.

3.2. INSIGHTS: SUPPORTING OTHERS EMOTIONALLY 3.2.4 Difficulties involved in providing emotional support for others Most young people we spoke to - who may not be experiencing mental health problems of their own - are acting in some way or another as a means of support for those who are, often without fully realising that this is what they are doing. Many feel at a loss at what best to do and say in order to help, and few seek any kind of formal advice in this regard. Issues of trust may mean that these young people feel obliged to keep friend’s problems secret, despite this perhaps not be in their best interest. Providing emotional support to others can be detrimental to the young person’s own mental health if they take on too much of the emotional burden and don’t receive support for doing so. Even when doing so in an official capacity - one young man had acted as a designated ‘mentor’ to younger pupils within school - having the responsibility of caring for others can be emotionally draining and upsetting. As one young person concisely put it: “you are never prepared enough for when something really bad happens.”

“I LIKE HELPING MY LITTLE SISTER OUT, I WANT TO LOOK AFTER HER ... ITS ALWAYS GOOD TO HELP OTHER PEOPLE. BUT YEAH, SOMETIMES ITS REALLY DIFFICULT TO KNOW WHAT TO SAY OR WHAT TO DO WHEN SOMEONE COMES TO YOU. YOU ARE NEVER PREPARED ENOUGH FOR WHEN SOMETHING REALLY BAD HAPPENS.” 3.2.5 ‘Helper Theory’ In contrast to the previous point, however, for those receiving a lot of support for in particular, being able to help others in return seems important for their own wellbeing. It creates a sense of balance, helps prevent the young person from becoming a passive ‘victim’ and allows them to actualise (and better understand through sharing) some of the advise they have received themselves. The benefits of helping is not, however, restricted to those young people living with recognised mental health difficulties, and was seen by the young people to have a positive effect on wellbeing.

3.2. INSIGHTS: EMOTIONAL LITERACY / THE THIRD SPACE 3.2.6 Emotional Literacy Ideas on emotional literacy were discussed in various guises during the engagement sessions. Suggestions were made for specialist teachers to give lessons at schools and colleges in how to deal effectively with emotions and care for and manage your mental health. The possibility of parents and other family members also attending was raised. It was generally agreed that the effective expression of emotions and sharing of problems in a constructive manner was key to long term mental wellbeing. Creativity was mentioned as a means of creating a positive emotional outlet. Education in this way, and also about the day to day realities of living with mental illness, was discussed as a means to fight stigma. The concept of greater openness and honesty within close social networks was seen as important: “Its all about being honest. Being honest with yourself about how you feel, as well as being honest with other people.” For some, it was only through hearing a confession from a friend that they were able to find the courage or push they need in order to voice their own difficulties. There was an awareness that all kinds of emotional barriers and a sense of stigma prevented this from often being the case. The encouragement of self realisation and the building of self confidence and esteem was also seen as vital by many of the young people. It was felt that schools, families and beyond should encourage a sense of individual self and celebrate achievements and individual strengths in everyone, irrespective of academic or sporting prowess. One young person even quoted Einstein in getting this point across: “if you judge a fish by its ability to climb a tree, it’ll spend its whole life believing that it is stupid”. The tendency towards self depreciation was also discussed as negative in regards to self esteem and well being; this was even seen as culturally indemic: “its just part of British society, we’re all really self-depreciating.”

3.2.7 The importance of the ‘third space’ (in terms of social spaces) for mental wellbeing Having a ‘third social space’, a chosen space of shared interest, with friends and peers other than those from the ‘first space’ that is home and the ‘second space’ of school or college, is important for wellbeing. The third social space helps a young person to define who they are and who they wish to be, and to meet other people who have also chosen that particular space for the same purposes.

“WE SHOULD BE TAUGHT ABOUT HOW TO DEAL WITH OUR EMOTIONS AT SCHOOL. YOU DON’T GET TAUGHT THIS STUFF, BUT YOU COULD BE. YOU JUST GET LEFT TO FIGURE IT OUT ON YOUR OWN. WE SHOULD HAVE EMOTIONAL EXPERTS OR PYSCHOLOGIST TEACHING SOME LESSONS.”

3.2. INSIGHTS: THE GENDER DIVIDE 3.2.8 The gender divide Photo by ‘Alexph’ under a Creative Commons License

As discussed in the previous section, the idea that young men were generally less likely to discuss their emotions and admit difficulties was persistent in our engagement sessions. Whilst initially insisting that this was because “men aren’t as emotional as women”, on further discussion it became apparent that few actually believed this; rather that some men were less likely to share problems, for fear of seem weak and displaying vulnerability. The young men that came across as the most articulate and comfortable in openly expressing emotions and opinions on mental health were those within the Erskine Media Music Group. This may be down to various factors; they were a close knit group of friends for one, but also had a creative and socially acceptable outlet for their emotions in music and songwriting.

3.3. INSIGHTS: DIGITAL MEDIA SPECIFICALLY IN RELATION TO MENTAL HEALTH 3.3.1 Ways in which young people feel their social media use relates to their mental health

3.3.2 Ways in which young people seek support for mental health related issues through digital & social media

For most young people, the link between digital and social media was not immediately obvious. Those that were most able to draw direct connections between the two were the young people living with recognised and diagnosed mental health conditions; as such, mental health was closer to the forefront of their minds in all aspects of their lives. Some of these young people had actively sought support through social media and were aware of triggers that they may be subject to through their use social media sites.

Again, the only young people who admitted to having actively sought support for mental wellbeing through digital media were those living with recognised mental health difficulties. Amongst those that had, the Butterfly Project in particular was well known (see pg 22 of the mapping document). A group of young women enjoyed practising the coping mechanism promoted on the site; namely drawing butterflies on to your own skin, or on that of a friend as a visible means of support. This simple and beautiful message of hope was very much appreciated, with one young woman even having had a butterfly tattoo in celebration of the campaign. The stories shared on the site were also appreciated, but seemed secondary in importance to the campaign’s motif and visual symbol of solidarity.

However, once prompted to further discussion of what mental health entails, the young people were able to identify instances online that affected their mental wellbeing. Bullying and abuse were key concerns, and arguments started on networking sites were also a hot topic. One young person suggested that: “all arguments seem to start on Facebook.” They expanded up on this, citing the fact that the increasing exposure of personal information to wider social networks, and the fact that conversations perhaps best suited to being held privately were instead carried out in a public digital space. The lack of face to face contact was also seen to sometime lower barriers of self control when angry or upset. There was also a consensus that ‘attention seeking’ behaviour on social networking sites, Facebook in particular, would often denote underlying emotional difficulties. However, few pitied those ‘attention seeking’ users, believing that they were more than likely exaggerating these difficulties and enjoying doing so.

A few young people said that they were members of mental health communities on Tumblr. They appreciated the feeling of connection to others in similar situations, and of being able to compare experiences, to find that “some people have it so much worse”. They were aware of the existence of negative pro-self harm and pro-anorexia Tumblr streams and professed to avoid them, although the difficulty of stumbling across such communities (or even deliberately seeking them out) when in a vulnerable mental state was discussed. Forums were also used for similar reasons, but also as a means to self diagnosis.

3.3. INSIGHTS: DIGITAL MEDIA SPECIFICALLY IN RELATION TO MENTAL HEALTH 3.3.3 Comparision of different social media sites in relation to mental health related issues and communities Most young people agreed that they were unlikely to discuss serious mental health related issues on Facebook, except perhaps through a private message to a trusted individual. Whilst it was common to complain of problems or express fleeting emotions, deeper distress is less likely to be disclosed publically. In contrast, a few young people said they had shared difficulties on Tumblr, due to the anonymity it offered and the fact that the stream was dedicated to the discussion of mental health. Grief was an interesting exception to this. Anniversaries of the death of loved ones are often announced through simple, heartfelt public messages posted to Facebook, and not only by young users. The sheer volume of supportive comments and ‘likes’ received aid consulation. Young people discussed having seen similar posts left on YouTube comment streams, often in connection to a significant song.

3.3.4 Self Management of Mental Health and Social Media A few young people in particular, (again, those already diagnosed and living with mental illness) were very active and mature in their approach, utilising trigger filters when using mental health related Tumblr streams, setting conversation parameters when talking to other users of mental health forums and avoiding sites known to have a negative approach. Amongst the young people not diagnosed with a mental health problem, many also demonstrated intuitive risk management, as was discussed in section 5.1.

3.3.5 Cyberbullying and ‘Trolling’ Trolling was a great topic of discussion amongst the young people and of course it was something that was viewed as negative and that needed to be prevented. As none of the young people admitted to being an internet ‘troll’, it is difficult to draw any first hand conclusions about this behaviour. However, one young person insightfully remarked that the ‘trolls’ were likely to need as much support as regards mental health as those that they abused, but that they would likely be unable to admit to any problems. There seemed to be a very fine line between what was classed as jokes and ‘banter’ shared online between young men of high school age particularly and bullying behaviour.

“ITS THE PEOPLE DOING THE TROLLING THAT PROBABLY NEED THE MOST HELP. TROLLS TROLL BECAUSE THEY HAVE THEIR OWN ISSUES, BUT THEY ARE THE ONES THAT ARE THE LEAST LIKELY TO ASK FOR HELP OR THINK THAT THEY NEED IT.”

FINDINGS CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 4 CO-DESIGN SESSION OUTCOMES THIS SECTION PRESENTS THE IDEAS DEVELOPED BY A CORE TEAM OF YOUNG PEOPLE DURING TWO CO-DESIGN SESSIONS.

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

CHAPTER 4 OUTCOMES OF CO-DESIGN SESSIONS

CHAPTER 5 DESK RESEARCH FINDINGS

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

READ READ

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READ READ READ

CO-DESIGN SESSIONS OUTLINE The young people were encouraged in free and imaginative idea generation through games, sketching and visual brainstorming techniques. An entire wall of vibrant ideas was created. The young people were then asked to categorise their ideas into: Intitial Ideas These were interesting thoughts and could make up fragments of potential services. Specific Service Ideas These comprise the ideas that could be worked up as entire services in their own right. We then present two ideas that the young people chose to develop and think about further: ‘Button Wall’ and ‘Support2’. These are by no means finished designs, but provide stimulation for discussion and insights. Youth guide Finally, the young people created advice for other young people on mental health considerations in relation to digital media, and an innovative format to present this.

4.1 THE YOUNG PEOPLE’S IDEAS: INITIAL IDEAS Below are catergorised the initial ideas that the young people put forward as means for helping develop services. They could provide inspiration for a visual identity, mood, function or touchpoint for services. They are written in the young people’s own words. Advice sharing: ‘Share ways for coping in different ways; the feeling – use ice instead, use a pen – draw it on/scribble on paper, tear paper, hit a pillow.’ ‘Share tips and tricks of how to cope with mental illness from people with experience’ ‘Give advice on reacting well to difficult situations.’ Ideas to help externalise negative thoughts then to attempt to move on from them positively: ‘You could write you problems in bubbles then pop them away.’ ‘Write your thoughts on a paper plane and throw it off a hill.’ ‘Put all your negative thoughts and

your anger into a drawing of a stickperson and then you choose how to destroy it.’ ‘Tell it to the man on the moon!’ Thoughts on externalising problems: Have a confession box: anonymity options allow people the security of letting out their secrets. Helpline – you could sign-up, and it would help you solve problems and work through problems. Meet ups and Events: Have mental health group trips – to share feelings and talk honestly together about your flaws. Have a mental health cruise (to Gartnaval - suggested as a joke!). The event would be called ‘We’re all in the same boat’: to show that you’re not alone and to make friends. Events in a butterfly sanctuary! Hold a mental health treasure hunt across the city.

4.1 THE YOUNG PEOPLE’S IDEAS: INITIAL IDEAS Aesthetics and approach for new services:

cuteness, butterflies, just generally nice things to look at.’

‘The film Scott Pilgrim is great to think about for style; it is all about someone’s mental health, but it is told in a really awesome and stylish way. It is funny and it looks good.’

‘Have a jar full of good thoughts/ things that happen.’

‘Mental health shouldn’t be dramatised in a really serious way.’ ‘Cats can be used as they naturally make people happy!’ ‘Have a contrast of styles – Spongebob Squarepants is an example, it is fun and deep. ‘People should be shown what you should do to help yourself, rather than what you shouldn’t.’ Ways to support wellbeing and recovery: ‘Have a list Short/long-term do’s and don’ts. Practical and emotional things.’

‘Write a letter to your future self.’ ‘Pets for everyone! Looking after something else is really good for you.’ Gaming: ‘Games for guys – they could shoot their problems!’ ‘Digital pet, where looking after it teaches you how to look after your own mental health.’ Campaigns: Have videos where celebs and fictional characters give messages of hope and positivity.

‘Have a recovery tracker.’

Have a campaign that lets guys know that it is a sign of strength to express your thoughts: ‘ Be a MAN and share your thoughts’

‘Send people small things - like motivational cats - to brighten up someone’s day; animals – cats,

Find positive symbols of freedom & recovery, such as the butterflies associated with The Butterfly Project”

4.1 THE YOUNG PEOPLE’S IDEAS: INITIAL IDEAS Emotional release: ‘You could shout horrible things through a megaphone and a only nice things would come out.’ You could have an anger translation service. You would say all the angry things you want to say to someone, then they would be translated into calm polite phrases. There would be a really polite cat butler saying them and he would be dressed in a suit.’

‘We need specialist mental health teachers.’ ‘We should learn about young people with videos, worksheets, role play.’ ‘You could educate through drama workshops – where you put yourselves in someone elses shoes.’

Ideas about education: ‘We need better understanding of mental health: talk about how it can affect everyone.’ ‘Better training on mental health in schools: have a lived experience training expert.’ ‘Regular and really good mental health education in school: better training for teachers.’ ‘People must be educated better in school to understand and break stigma.’ ‘It’s about educating the younger generations.’

4.1 THE YOUNG PEOPLE’S IDEAS: SPECIFIC SERVICE IDEAS Ideas that the young people felt could be best worked into services included: Youth Are Not Alone ‘A Safe online community for all mentally ill young people to talk and share stories and tips.’ Flow ‘A planning app where you write down what you want to achieve and it reminds you. It checks later in the day if you’ve done it, if not it makes you feel ok about it.’ Button Wall ‘A wall of badges (clickable) with fun pictures, messages and tips and other helpful things.’ Cope ‘Sending you own coping mechanism for others to use’ Support2 ‘A service specifically for those supporting people affected by mental health.’

???!!! ‘Post/submit serious statements relating to mental health then someone makes a funny cartoon about it (maybe a comic/ have reoccurring characters)’ Anger Translator ‘A website where you can go when you feel angry/frustrated; you can write down and it will tell you something you can say instead that won’t cause problems/a fight. Helps you get the anger out.’ Thoughts & Crosses ‘Public post-it note like wall of thoughts. You write out your thoughts and cross out negative thoughts … then write a positive thought in return.’

The young people selected ‘Button Wall’ and ‘Support2’ for further development, as explained in the following pages.

Postcards ‘Other people’s stories and feelings in postcard form.’

4.2 DEVELOPING IDEAS: BUTTON WALL As the young people developed button wall, the initial idea for a badge-based aesthetic was left behind and the core of the concept was expanded upon. Users would be able to search through and compile their own themed ‘streams’ of information. These streams would contain tagged images, videos, music, quotes and helpful tips and advice. Rather than these streams being displayed in a linear, chronological format as is common on social media sites, the content would be represented by a series of connected points. Each point would contain one easily shared and digested piece of content. These points would interconnect with similar content in other streams, allowing the user to consume information in interesting and thoughtful ways, and to see connections between themes and other users. When the site launched, it would contain official information and advice streams. There would be a wide variety of streams. Examples could include:“Positive coping mechanisms” / “What it is like to suffer from Depression” / “Positive

change theme

YEAH, CATS!

BUTTON

wall

by jamie

search:

‘inspirational Images’

by jenny b

inspiration, cats

#inspiration #cat #comeon

Keep on keepin’ on! Even grumpy cat is cheering you! ADD TO MY STREAM

4.2 DEVELOPING IDEAS: BUTTON WALL steps to good mental healthâ&#x20AC;? / Antibullying inspirationâ&#x20AC;? amongst many others. All visitors would be able to flick through these streams or search for one specific piece of content using a search bar. If they decided to join up and use the service more actively, users would be able to create their own information streams. They could add content they enjoyed from the official streams to their own, or add their own uploaded content. Users streams would be held on a home page and kept private by default. However, they could also choose to share the streams with friends using the site, provided that they were able to give the email addresses of these friends. If the user wanted to make a particular stream public, it would have to be sent to a moderator first, as would any information added. No direct communication would be permitted between users to enable safeguarding, but you would be able to see if content in your own stream appeared in other streams.

change theme

BUTTON

wall

search: MY STREAMS Inspiration Coping mechanisms My moods Cute animals!

PUBLIC PUBLIC PRIVATE SHARED WITH ...

NEW STREAM ADD TO STREAM DELETE STREAM

4.2 DEVELOPING IDEAS: BUTTON WALL A connection link would be made between streams when content was added from one to another. The poster of the content could tag it and leave a comment, but others would not be able to comment back.

change theme

BUTTON

wall

Useful template streams could be in place for users to add to. These could include templates for mood trackers. Users could set attractive themes and backgrounds for the visible appearance of their account. The young people were very keen that the site (and app version) be beautiful and poetic, to encourage positive use of it. It was to have a clear central mission statement an ethos.

search: MY STREAMS Inspiration Coping mechanisms My moods Cute animals!

PUBLIC PUBLIC PRIVATE SHARED WITH ...

#cute #seal #hope

Feel good!

NEW STREAM ADD TO STREAM DELETE STREAM

4.2 DEVELOPING IDEAS: SUPPORT2 Support2 was imagined as a platform site with a selection of tools available. Central to the idea is the framing of the site; it should be aimed at young people who are concerned for, or actively supporting, someone with a mental health problem. The site would involve a wider media campaign encouraging young people to look out for each others wellbeing. The side would include: A story sharing section Young people could share their own stories and concerns and read stories of others. This cold be done through plain text for longer stories, or they could choose to use the visual tool for short â&#x20AC;&#x2DC;confessionsâ&#x20AC;&#x2122; and advice. This tool allows them to choose an image from a user generated, but moderated, bank as a background, and add text in a font of their choice. Forums These would be themed and allow young people to discuss their concerns with other users and experts. Experts would have designated time slots where they

4.2 DEVELOPING IDEAS: SUPPORT2 would answer questions in real time, but also play the role of the administrator. Negative comments would be able to be blocked and reported. Users would have to set their own trigger filters in order to begin using the forums. Messaging The young people we keen on being able to send each other messages and have chats through the site. They understood that this could be risky and came up with the idea of setting conversation parameters. These would be displayed on the young persons profile, and they would be sent programmed reminders to check that they were sticking to these.

4.3 SESSION OUTCOME: YOUTH GUIDE In the final co-design sessions, the young people came up with advice they would like to give other young people. The advice aimed to help young people use digital and social media in a manner that would support mental wellbeing and was grouped into 5 categories: 1. Looking out for your friends. 2. Combating cyberbullying. 3. Social media addiction. 4. Expressing emotions honestly and appropriately. 5. Avoiding negative content. Together with the young people, we then created a digital format for the advice that would allow it to be accessed and shared easily online by young people. An attractive, humerous animated .gif was created for each advice category. These act as advertising for the site and Facebook page that host the young people’s advice. Animated .gifs are frequently shared by young people on social media sites and would allow for rapid peer dissemination. The advice was presented as a series of attractive graphic ‘postcards’ that can be shared individually via social media, but also stored together in an album.

4.4 INSIGHTS ARISING FROM CO-DESIGN SESSIONS As a result of these sessions and ideas and a follow-up co-design session carried out with project team members from the NHS, we are able to draw some key insights to reflect the kinds of services that may aid young people: An imaginative, multimedia ‘moodtracker’ / tool for expressing and understanding mood and emotions There is a clear need for a ‘moodtracker’ type tool that goes beyond recording emotions and states of mind in numerical or ‘sliding scale’ form. For the young people we worked with, the subtlety of emotions was far better expressed and realised through images, animations and video clips, music, quotes from literature and poetry, and stories. An effective tool would ask young users to select and store such content in order to express their emotional state as richly as possible, but also prompt them to reflect on what they had chosen and to work out why they had done so. Such a tool has great potential for linking with services provided

by GPs, counsellors and CAMHS teams. In this case - particularly in regards to the tight timeframe GP appointments are governed by - it would be important that such a tool would prompt young users prior to an appointment to filter through and select the content they feel will be most useful to express their state of mind, and to work out how they could explain this to someone else. In lengthier counselling sessions, it may be feasible and advantageous to work through more of the content in greater detail. Online communities Online communities centred on mental health issues exist in abundance and thanks to the anonymity and solidarity they offer, vulnerable young people are often able to discuss and find support for issues that they otherwise might not offline. However, unmonitored communities can negatively affect young person’s wellbeing. Proanorexia and pro-self-harm online groups, for example, do exist. That is not to say that some online communities aren’t able to selfmanage very well, but there is a real need (and desire amongst some

of the young people we worked with) for properly controlled and monitored forum environments, that allow young people to share advice, stories and support amongst themselves, but also to receive expert input and guidance. Forum discussions could be monitored by professionals, who would offer official advice on the forum topic and respond to individual comments. They would essentially act as discussion invigilators, looking out for both the general mood of the discussions and for the wellbeing of the individual contributors. They would have the power to hide inappropriate comments and to contact any users they become concerned about through means of a private message. They would also be contactable for any users that become distressed or uncomfortable with comments made in the forum. Such professional involvement could prove costly, so again, the effectiveness of such a service would depend on the correct managing of users’ expectations of the level of professional involvement, but also on fostering a positive forum environment that

promotes self-regulation. There could, for example, be allotted times at which users can ask questions directly to a mental health professional; at all other times their involvement would be far more ‘hands-off’, perhaps only acting only if alerted to something by forum members. Forum themes should be framed in a positive manner and clear parameters set for the expected behaviour of users. Each user could be asked to set trigger warnings and appropriate trigger filters would need to be in place. Users would be encouraged to report anything inappropriate or negative to the professional moderator and to be extremely mindful of their own and each other’s wellbeing. More careful research and co-design would be needed to identify ways in which to foster the most positive forum environment possible, but, as was suggested by a young person in our core co-design team, the key to this may lie in creating a clear, beautiful and positive identity for the forum space and its ethos. We can see through the ‘Support2’ idea, it is a natural instinct for young people to seek to build friendships with those that they

4.4 INSIGHTS ARISING FROM CO-DESIGN SESSIONS feel they connect with on certain issues. From this instinct comes the desire to be able to talk to others they might find on a forum on a one to one basis. Private messaging between forum users is not, however a function that we would recommend, due to all manner of problems with risk. Users should be asked not to give out email addresses and personal details, and this needs to be monitored by the discussion invigilator. Instead, forum users actively seeking friendship should be encouraged to attend local offline community and support groups. Trigger filters would also need to be in place. Users would be encouraged to report anything inappropriate or negative to the professional moderator and to be extremely mindful of their own and each otherâ&#x20AC;&#x2122;s wellbeing. More careful research and co-design would be needed to identify ways in which to foster the most positive forum environment possible, but, as was suggested by a young person in our core co-design team, the key to this may lie in creating a clear, beautiful and positive identity for the forum space and its ethos.

Services specifically aimed at young people helping others through mental difficulties This could include a host of services, including story sharing, forums, tips and advice on what best to say and do in different situations delivered through various imaginative and interesting means, etc. The most important thing about to stress, however, is the importance of framing a digital asset in this way. A huge number of young people, who may not be experiencing mental health problems of their own, are acting as support for those who are, often without fully realising that this is what they are doing. It is important that this is recognised and that they are provided with a space that will allow them to do this most effectively, but also allows them to vent concerns, and encourages them to look out for their own mental wellbeing whilst bearing anotherâ&#x20AC;&#x2122;s burden. It may be that some young people, that are difficult for mental health support services to reach for a host of reasons, can only be accessed via concerned friends and peers.

Equally, providing young people with the premise that they are seeking support for a friend rather than themselves may allow for greater engagement.

Dissemination of advice on how to maintain positive mental health Some of the young people we worked with found it difficult to name positive, everyday measures that would allow them to look after their mental health. This was in stark contrast to maintaining physical health, which all could discuss with confidence. Advice needs to be compiled and promoted that will encourage the day to day maintainence of good mental health. The most comprehensive and ambitious means to do so would be through an extensive campaign that would extend beyond a single digital online asset to the school curriculum, and would also attract opportunities for private companies and third sector groups. However, the power of rapid information dissemination online could be harnessed with a carefully thought

through digital campaign, that targeted social media sites such as Facebook and Twitter. This would need to utilise a range of techniques, mediums, styles (and most likely celebrity endorsements) that tied in with internet trends amongst young people at the time. Crucially, the information would need to be in a format that young people could adapt and share easily and may require a well-publicised event to act to stimulate interest. The campaign could also encourage active user participation in order to create sustained impact; users could, for example, be encouraged to share a positive thought, image or action each day in a social media stream, or send a positive message to a friend.

4.4 INSIGHTS ARISING FROM CO-DESIGN SESSIONS Practical, day-to-day tips for managing mental illness This is in close relation to the previous point, but specifically targeted at those managing a recognised mental condition. The young people highlighted the usefulness of creating ‘to-do’ lists and schedules that remind you to enact certain positive behaviours and give you a sense of reward for carrying out simple, daily tasks Feeling that you are able to take practical tangible steps to help you through the daily management of an illness is important. With the proliferation of smart phones, a calendar-type app designed specifically for different kinds of mental health management could prove a valuable digital asset. There was also an interest in sharing practical tips and positive coping mechanisms; this could be realised in a variety of online formats.

Empathy tools There was a desire especially amongst the young people to see and hear heartfelt, non-glamorised

accounts of what it is like to live with mental illness on a practical, day-to-day basis. These could be in a variety of formats; video, audio including song and spoken word, comic illustration, or simply written. Such accounts were seen as not only important to those suffering from mental ill health as a means to contextualise their own situation, but also as a means to fight stigma. A digital space for sharing such accounts, backed by a wider campaign, would be welcomed. -

Emergency 24 hour Instant Messaging service for people in distress This would act as an addition to the phone lines and drop in options provided by organisations such as the Samaritans. Young people, as digital natives, are very much at home communicating via instant messaging and online chat functions. For some vulnerable young people experiencing distress this could be a far more comfortable and intuitive option than a telephone conversation; some may even feel an inability to call for help. This would of course require

a great deal of training and for infrastructure to be put in place, but could be crucial.

Further exploration of the possibilities of gaming Gaming was discussed quite frequently during our initial engagement sessions, and although discussed in these co-desgin sessions, it did not feature heavily. This may well have to do with the fact that the core co-design group was entirely made up of young women. It was suggested that gaming might be useful to help young men in particular as an empathy tool or emotional release. There was also one idea for a game put forward that was not discussed in terms of gender, which involved young people looking after the health (both mental and physical) of a virtual pet. It wold act as a means to help young people best look after themselves.

‘Humour’ as a Support Tool Humour, used appropriately, is a powerful tool. There was a sense of frustration amongst the young people with recognised mental health problems that issues surrounding mental health were either addressed too delicately and seriously / clinically or with ignorant insensitivity. A well-informed, humorous approach would be favourable; careful co-design would be required in order to gauge this. It is a case of humour being used as a tool to enable young people to make light of their own situation in a constructive way in order to better cope with it and to share it; simultaneously insensitive jokes need to be called out as unacceptable.

Aesthetics of Digital Assets Any digital asset created should have distinct, interesting and beautiful identity and ethos, and clear expectations for use and behaviour. It is important to set the mood and personality of a digital space as carefully as that of a physical space. When a digital space

4.4 INSIGHTS ARISING FROM CO-DESIGN SESSIONS is bland and without clear rules and aims, its identity becomes solely defined by a critical mass of users. Whilst this may create positive results, it also allows negative behaviours to push to the fore unchecked: Askfm is a worst case example of this.

STEPS TO WELLBEING There was a consensus amongst the young people that we worked with that the ability to understand, express and share problems and emotions appropriately and constructively is crucial to mental wellbeing. It was understood that this would not necessarily prevent the onset of mental illness, but that such ability was necessary for positive self-management. Four basic steps to wellbeing began to emerge and the subsequent ideas they devised for mental health support services can be seen to align to these. >>>

1. Help young people

to express, understand and contextualise their emotions and problems.

4. To help young

people to maintain and promote mental wellbeing.

2. Help young

people to share these emotions and problems in a constructive and supported way.

3. Help young people to manage or work through their problems and emotions; to get the appropriate support to achieve this; to encourage them to help others do the same.

FINDINGS CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 5

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

DESK BASED RESEARCH

CHAPTER 4

THIS SECTION GIVES A SUMMARY OF PUBLISHED LITERATURE AND PRACTICE EXAMPLES, AND PRESENTS A PROTOTYPE MAP OF DIGITAL ASSETS FOR YOUNG PEOPLE’S MENTAL HEALTH.

CHAPTER 5

OUTCOMES OF CO-DESIGN SESSIONS

DESK RESEARCH FINDINGS

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

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READ

READ READ READ

CHAPTER 5: SUMMARY KEY FINDINGS There are challenges in presenting evidence in the digital field, when the pace of developments outstrips conventional methodologies for building an evidence base.

There is good evidence that digital participation through social networking services, gaming and peer communities has benefits for young peopleâ&#x20AC;&#x2122;s mental health.

Internet use is to all intents and purposes ubiquitous amongst young people in Scotland. Young people frequently access the internet using personal devices and mobile technology, and prioritise access to the internet in making choices on what to spend money on.

Participation in social networking services has been associated with positive identity development, engagement and participation in campaigning and political activities in communities and online, the development of creative skills, and the development of social capital.

Media literacy is a key determinant of young people being able to use digital technology to improve their mental health and wellbeing. This encompasses technical, social and academic aspects.

Finally, young people need to develop the critical skills to evaluate content and sources in deciding what to believe in terms of that they do online. Evidence suggests that the necessary skills for young people are not always available in schools.

Young people need the skills and access to use the devices, software and applications (apps) available in a useful and responsible way. They need to be aware of appropriate social use of the web in terms of managing unwanted attention, and conducting online relationships with respect.

KEY FINDINGS Creativity has long been associated with good mental health, and indeed with assisting people to make sense of and communicate their feelings in relation to distress and mental ill health. Young people have been at the leading edge of using digital media to express themselves and develop their identities using creativity. Collation and curation of media, and the production

of video, graphic and written content both individually and collaboratively has been associated with both positive mental health and peer support in recovery. There is work to be done to ensure young people understand copyright and intellectual property law in this regard, and are able to negotiate challenging content, including around suicide, eating disorders and sexual content.

There is a body of encouraging practice in terms of clinical use of technology for young peopleâ&#x20AC;&#x2122;s mental health. Online counselling and peer support shows some promise, and eCBT has been used successfully with young people, although evidence suggests that guided selfhelp with offline and online content helps young people to complete programmes. Young people specific mood

trackers have been developed and services have also begun to use online modalities to introduce services. For example SPARX in New Zealand uses online gaming and avatars (game characters representing the player) to guide young people through CBT activities.

KEY FINDINGS Evidence suggests that young people who are most at risk in the offline world are at most risk in the online world, a general theme in terms of assessing risk in digital environments. Young people with mental health problems or poor mental health are therefore even more likely than the general youth population to need guidance and support in making best use of the digital world, and managing the risks and opportunities present. Collin (2011) makes three central recommendations to policy and practice in relation to social networking use:

1. The concept of cyber-

citizenship should be mainstreamed and not confined to young people. Most policy frameworks emphasise young people and therefore talk in terms of what they should become, rather than what they already are. Collin proposed that cyber-citizenship policies and practice should include the community as a whole, as opposed to being constructed as a set of policies to protect young people from the digital environment; which they may be more adept at negotiating safely than many adults. This, Collin proposes, could have a positive effect in terms of young people working alongside adults in policy and practice to close the intergenerational gap that could widen as technology developments increase in pace still further.

2. The move the paradigm

of cyber-citizenship from one solely concentrated on risk management and protection, to one that includes the nurturing and recognition of the positive aspects of participation, such as creativity, sharing self-generated content and engagement with civil society. This, the reviewers conclude may mean that people in authority might have commonly held notions about childhood, gender, youth etc challenged. It would also necessitate the review of the way legal and ethical information on digital citizenship was presented.

3. Finally, Collin

recommends that in considering cybercitizenship, policy makers and practitioners should take a holistic view of the way peopleâ&#x20AC;&#x2122;s digital lives interrelate with their work, home, school and leisure time, as opposed to emphasising an artificial distinction between online and offline worlds.

FINDINGS THROUGH DESK RESEARCH: INTRODUCTION Introduction This rapid review is intended to frame the context for the project field work, and provide a selection of key points from the literature, and from practice in Scotland, the UK and beyond. We begin with a brief analysis of quantative data gathered through a survey by Young Scot. We continue with a summary of available literature and practice. There have been several recent comprehensive literature reviews in this area,

including on technology, mental health and young people generally (Powell et al 2010), the benefits of social networking to wellbeing (Collin et all 2011), vulnerability (Singh et al 2011, 2013), and the mental health impact of gaming (Johnson et al 2013). We draw on these to summarise key learning here, but urge readers wanting a more detailed analysis of the literature to consult these reviews.

We have also created a prototype mapping framework which presents a wider range of example practice examples in the field by audience sector and by activity (presented as a separate document in the Appendices.) This was developed from the research output, and was populated with a selection of examples of digital initiatives from the UK and beyond at a mapping session involving the partners. The prototype map is presented as an outline for discussion with

the project team, for further development. Examples have been placed in the map using the considered judgement of project team members, in keeping with the illustrative approach commissioned here. We have not conducted a detailed assessment of the content presented online by the example initiatives, so cannot quality assure them for use by professionals in their work with young people.

5.1 SUMMARY OF QUANTATIVE DATA: INTERNET USE IN YOUNG PEOPLE IN 2012, 51% OF 16 TO 24 OF SMARTPHONE USERS AGREED WITH THE STATEMENT: “MY PHONE IS MORE IMPORTANT TO ME FOR ACCESSING THE INTERNET THAN ANY OTHER DEVICE.” In 2011 the level was at 33% net agreement compared to 42% net agreement in 2012. (ofcom uk-4.03)

The extent and manner of internet use by young people Mobile internet usage has grown quickly over the last three years, with young people leading the way as early adopters in both hardware (mobile and tablet handsets) and in internet and app usage. The rise of mobile internet access in young people has continued to grow into 2013 with visits to www. youngscot.org from mobile devices in July 2011 at 7% of overall visits, in July 2012 it was 24% and in July 2013 this figure was over 42%. For health-related topics this figure is even higher with mobile visits for health information website www. getthelowdown.co.uk at 54.5% of overall visits in July 2013. According to a Young Scot survey in June 2013, 95.7% of respondents owned a mobile phone. 37% of these young people said the spent between 1-2 hours on their mobile devices each day and 42% of respondents said they spent over 2 hours on their mobile devices.. Of the time spent on a mobile device the estimated percentage

of that time spent on “social” apps such as Facebook or Twitter was 38%, using the internet: 35%, playing games: 18%, and “using other apps”: 14%. Social Networking apps were heavily used on mobile devices with over 80% of respondents using Facebook, 53% using Twitter and over 89% using YouTube.

ALL OF THE MOST POPULAR APPS WERE FREE WITH 84% OF YOUNG PEOPLE SAYING THAT THEY “RARELY” OR “NEVER” BUY APPS.

Scotland is still behind the UK average for Broadband take-up, although gaining ground. 68% of homes in Scotland now have broadband, up from 61% a year earlier: “Broadband take-up in Scotland has risen faster than any other UK nation over the last year, jumping 7 percentage points over 2011.” The Communication Market Report: Scotland (2012) Glasgow is 17% down on the national average for Broadband. Young people have a higher penetration rate of 3G (mobile broadband) people than the national average of 77%. See fig 1 overleaf for an infographic summary of research.

YOUNG SCOT SURVEY: MOBILE, INTERNET AND APPS

April-June â&#x20AC;&#x2DC;13

634 responses

OFCOM OMNIBUS RESEARCH

MOBILE PHONES USE

38%

35%

18%

14%

Social Apps

Internet Browsing

Video Games

Other Apps

11-26 YO

RESULTS

MOBILE PHONES USE

MONEY

95.7%

84%

Own mobile phones

42%

Use their mobile 2 hrs/per day

rarely or never buy phone apps

37%

Use their mobile 1-2 hrs/per day Fig 1. The extent and manner of internet use by young people

OFCOM OMNIBUS RESEARCH

March ‘12 & ‘13

51% Connect to the internet with their phones.

THE COMMUNICATIONS MARKET REPORT: SCOTLAND

2012

68% Homes in Scotland have broad band.

THE CARNEGIE UK TRUST: “ACROSS THE DIVIDE TACKLING DIGITAL EXCLUSION IN GLASGOW

GLASGOW

2013

51% Homes in Glasgow have broad band.

THE WORLD CELLULAR INFORMATION (WCIS)

YOUNG PEOPLE 3G PENETRATION IN THE UK

NATIONAL 3G PENETRATION RATE OF 77%

5.2 SUMMARY OF LITERATURE: THE POTENTIAL OF SOCIAL MEDIA The potential for social networking services to improve and protect young people’s mental health Public and media discourse on internet and technology use by young people often concentrates on the risks posed by factors such as cyber bullying, exploitation, overuse and withdrawal from faceto-face interaction. A set of common negative perceptions about the effect of social media, gaming and other online interactions have arisen, when though risks to need to measured, there is a lot of evidence to suggest positive benefits to mental health from a range of online practices. These benefits are indicated across a spectrum of young people, from those with mental health problems or long term conditions, to those in distress or at risk of poor mental health due to exclusion or isolation, to a general population of young people. The Australian Cooperative Research Centre for Young People, Technology and Wellbeing1 (YAW-CRC) was founded in 2010 to bring together academic, voluntary sector and commercial partners to collaborate on research and innovation in young people, digital and mental health research. The organisation

has invested substantially in high quality literature reviews, and syntheses of practice, as well as adding substantially to the evidence base through developing, piloting, and evaluating methods of engaging young people and other stakeholders in the field.

The Collin review, key findings of which are summarised below, concentrates principally on the positive aspects for mental health and wellbeing of social networking services, placing these in the context of widely reported risks, and calling for a review in our approach to cybercitizenship as being the best route to addressing both risk and leveraging opportunity. They summarise their top level findings thus:

In 2011, YAW-CRC published a major literature review on the benefit of social networking services for young people (Collin et al, 2011). They use the broad Boyd and Ellison (2008) definition of a social network services as:

“… THERE ARE A NUMBER OF SIGNIFICANT BENEFITS ASSOCIATED WITH THE USE OF SOCIAL NETWORKING SERVICES (SNS) INCLUDING: DELIVERING EDUCATIONAL OUTCOMES; FACILITATING SUPPORTIVE RELATIONSHIPS; IDENTITY FORMATION; AND, PROMOTING A SENSE OF BELONGING AND SELF ESTEEM ...”

“web-based services that allow individuals to (1) construct a public or semi-public profile within a bounded system, (2) articulate a list of other users with whom they share a connection, and (3) view and traverse their list of connections and those made by others within the system. The nature and nomenclature of these connections may vary from site to site.” Boyd and Ellison (2007)

Collin et al. (2011)

5.2 SUMMARY OF LITERATURE: THE POTENTIAL OF SOCIAL MEDIA Further to this, they suggest that: “the strong sense of community and belonging fostered by SNS has the potential to promote resilience, which helps young people to successfully adapt to change and stressful events.”

Further key recommendations of the Collin review can be found summarised in the table overleaf.

However, they emphasise that for these positive aspects to be fully realised, they rely on a level of awareness of good ‘cyber-citizenship’ amongst young people:

“IMPORTANTLY, THE BENEFITS OF SNS USE ARE DEPENDENT ON GOOD INTERNET AND MEDIA LITERACY: HAVING THE SKILLS TO ANALYSE AND CREATE MEDIA CONTENT. MAXIMISING THE BENEFITS OF SNS AND PROMOTING INTERNET AND MEDIA LITERACY MAY HELP PROTECT YOUNG PEOPLE FROM MANY OF THE RISKS OF ONLINE INTERACTION, SUCH AS CYBER-BULLYING.” Collin et al. (2011) 95

THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 1. MEDIA LITERACY Underpinning their comprehensive examination of evidence to support the positive value of social networking services across the spectrum of mental health promoting activities described above, Collin points to the need to ensure that the opportunities provided by interpersonal communication online are balanced by ensuring that renewed media literacy work with young people enables them to take the opportunities afforded, and to avoid the risks. The review describes a number of components to online media literacy. These include: >>>

Critical content literacy The ability to use search engines, appreciate how they order information and to consider sources and appraise the credibility of information.

Communicative and social networking literacy An appreciation of the range of online communication methods, the appropriate and safe use of these, the norms for online communication and how to manage privacy and unwanted communication.

Creative content and visual literacy An understanding of how to create content using media, and an appreciation of how to use this appropriately, and within copyright where applicable.

Mobile media literacy An understanding and awareness of the etiquette of mobile device use, and the norms and conventions of online communication on mobile devices.

The review highlights evidence that supports the assertion that ‘learning by doing’ with social media helps young people to develop media literacy, creative content and visual literacy and technical literacy in terms of creating, sharing and using online content that isn’t always part of the school curriculum. Similarly, there is a need to ensure that young people are guided in terms of copyright, privacy, and critical appraisal of information.

Technical literacy The knowledge and skills to use a device, software, or app.

THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 2. FORMAL & INFORMAL LEARNING The review points to the value of online learning environments and the potential for personal devices and ICT in schools to improve learning outcomes. To some extent this is already recognised in Scotland and the UK. The review points to a dearth of evidence in terms of the effect of social media in formal education (as 2008), in part because of the restriction of social media in some schools and states in Australia (Notley 2009). That said, the review points to positive examples of social media use in bringing together students from diverse geographical areas, or from different cultural backgrounds. Additionally there is some evidence suggesting that social network service use

between teachers and students can improve rapport, motivation and engagement with education (Mazer et al 2007). There is evidence to indicate that use of social networking services can assist young people in learning and skills development outside formal environments. This includes development of transferable skills relevant to the modern workplace (Notley 2009); collaborative skills and sharing content in communities of interest; and in understanding of citizenship. (Ito et al, 2006; Jenkins 2007). Because participation in social networking services can be highly personalised and controlled, the sense of personal agency they can create can make them important tools

for learning for those who struggle in traditional learning environments (Green, 2007) or have specific interests or needs, such as young parents (Notley 2009).

THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 3. CREATIVITY, IDENTITY & EXPRESSION Social networking services and social media have rapidly created multiple avenues for media consumers/users to create and share their own content. This includes original content such as artwork, writing video and images; and ‘remixed’ content, such as playlists, animated pictures (GIFs). Young people have become particularly competent in producing and disseminating their own ‘small media’ as part of everyday life (Collin et al, 2011). The positive benefits to young people in terms of their development of a sense of community and identity are wide. These include development of literacy; a sense of aspiration and self-worth, including getting feedback and validation to develop skills; encouraging

experimentation and exploration with identity, and reinforcement and validation of aspects of cultural or personal identity. Finally, collaborative creative activities have been shown to foster connection with others and a sense of community, whether or not these communities are long term or ephemeral (Richardson, Third and MacColl, 2009) Ito and Okabe (2005), in a report entitled ‘Personal, Portable and Pedestrian’ on the use of mobile devices in Japansese culture reported the role that sharing and curating multimedia content with a small group of people in a collaborative space helped to build a sense of collective belonging. This is eerily similar to the way in which social media channels such as Twitter,

Tumblr and wiki/fan pages work now. Linked to the sense of community identity created by young people online, social network services are also becoming key to young people’s expressions of their personal identity. This is enabled by the high degree of personalisation possible within the framework of the services. A sense of belonging and acceptance, for example of sexual orientation, gender diversity or disability can arise from collective identification with geographically and culturally diverse individuals with a peer connection (Harris 2004, Hiller and Harrison 2007, Munt, Basset and O’Riordan 2002). The connection to online communities can endure

even after an initial impetus is gone (Richardson and Third, 2009), a phenomenon often observed in mental health forums, and which can be utilised in terms of recruiting moderators trusted by members, a practice developed as a volunteering opportunity by YouthNet for TheSite. Young people are using social networking services to experiment and seek legitimacy for political, sexual, ethnic and cultural identities (Coleman and Rowe, 2005; Montgomery et al 2004, Hillier and Harrison 2007) This has been well demonstrated in groups of young people exposed to risk of poor mental health, including new migrants, BME groups and young people with long-term

THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 3. CREATIVITY, IDENTITY & EXPRESSION Rare conditions groups such as Brittle Bone UK and Action for ME have also used online collaboration to connect distant young people with a peer connection. The phenomenon is also apparent in any examination of the way young people with mental health problems use social media to express their feelings and seek validation and peer connections. Civic involvement and connection to decision making in communities is associated with good mental health. Social networking services provide a range of new spaces and environments for civil and political activity (Montgomery 2007, Vromen 2007). Organisations and services are increasingly looking to use social

networking and social networking practice to engage young people in government and community decision making (Collin, 2010). In Scotland, organisations like Young Scot, NUS Scotland and the Scottish Youth Parliament have sought to develop young people’s interest and capacity to engage with civic activities using online communication, and it will be interesting to note the effect that extending the franchise for the independence referendum to 16 year olds may have on the use of social media in the debate.

4. STRENGTHENING SOCIAL RELATIONSHIPS Strong interpersonal relationships are critical for the development of good mental health, and the resilience young people need to face challenge. Social networking services have been shown to play an important role in developing and strengthening relationships of all kinds, both in terms of strengthening existing relationships and creating new ones. In terms of strengthening existing relationships, internet use in general has been found to strengthen young people’s interpersonal relationships. Concerns such as lack of places for young people to meet in communities, and lack of time and space outwith school and structured activities can be addressed

by social networking and social media, which challenge these boundaries. Equally, social media use has been shown to address concerns and maintain social networks when complexity (such as illness) or mobility (such as moving town or transitioning to college/university from school) interfere with face to face social networks. Facebook was founded to enable members of college classes to keep in touch, and research has suggested that students with lower selfesteem and satisfaction with university life have benefitted most from active use of Facebook (Ellison, Steinfield and Lampe 2007) Social networking services have also become a key part of young people’s exploration

THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 4. STRENGTHENING SOCIAL RELATIONSHIPS relationships, particularly with the proliferation of own device internet use via mobile phones. (Livingstone 2008) Recent news stories have highlighted the potential for abuse, exploitation and breaches of trust to lead to tragic consequences in this regard. Equally, it seems clear that most young people have adapted to use of social networking services more rapidly than people of earlier generations, who are often responsible for educating and supporting young people to have these conversations. Traditionally, research has focused on social networking services in the maintenance of existing relationships. There has been often been a suggestion that relationships which occur solely online are

‘weaker’ (Donath and Boyd, 2004). There is evidence to suggest though that for some of the most marginalised or socially/ literally isolated young people, online connections with peers can be a key source of social contact. Third and Richardson (2010) point to a study of young people with long term conditions using an online community, who described the friends they made there as ‘true friends’ that were ‘amongst the most dependable and enduring’. Facebook has been associated with helping young people with less developed social skills to develop friendships that then translated offline (Valkenburg et al, 2005). Finally, connection made with others in online environments can enable and encourage

marginalised groups of young people to develop the confidence to utilise assets in their communities to address concerns.(Munt, Basset and O’Riordan, 2002) Differentiation of social networking use with new versus existing relationships is based on an ‘assumed distinction’ between the two. Increasingly, evidence points to young people viewing online conditions.

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5.2 SUMMARY OF LITERATURE: GAMING AND WELLBEING Gaming and Wellbeing The Young and Well CRC Gaming Research Group published a comprehensive review on the state of play in research linking videogames to flourishing mental health, responding to concerns about the potential negative effects of gaming. They summarise their findings:

They continue to discuss gaming in a nuanced fahsion: “Emerging research suggests that how young people play as well as whom they play with may be more important in terms of wellbeing than what they play. Further research is needed to explore key questions including the moderating influence of personal characteristics on the relationship between videogames and wellbeing and extending existing research by replicating findings across game types, demographic samples and play environments.”

“EXISTING RESEARCH SUGGESTS THAT VIDEOGAMES CONTRIBUTE TO YOUNG PEOPLE’S EMOTIONAL, SOCIAL AND PYSCHOLOGICAL WELLBEING ... VIDEOGAMES HAVE BEEN SHOWN TO POSITIVELY Johnson et al, 2013 INFLUENCE YOUNG PEOPLES The review discuses evidence to support a positive role for gaming in EMOTIONAL STATE, SELF-ESTEEM, emotional intelligence and control, building of healthy relationships and OPTIMISM, VITALITY, RESILIENCE, social capital, including between those from marginalised groups, ENGAGEMENT, RELATIONSHIPS, SENSE and improvements in self-esteem. Furthermore, evidence suggests that OF COMPETENCE ... AND SOCIAL even playing violent games can can have creative, social and emotional CONNECTIONS AND FUNCTIONING.” benefits. The degree of violence

suggest that further research might concentrate on the ways in which character selection, game choices and styles of play may influence wellbeing. Frequency of play did not significantly relate to neither body mass index nor school performance. The review also points to evidence that gaming can be a successful play therapy tool, being helped to change their views of themselves and others through the use of metaphors in games, such as collecting attributes or conquering tasks.

Johnson et al. (2013) is not a key factor in determining

enjoyment, through the review does

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5.2 SUMMARY OF LITERATURE: GAMING AND WELLBEING In New Zealand, the benefits of using fantasy games was harnessed in the development of SPARX, a game based method of delivering computerised CBT. In a controlled trial of SPARX, Merry et al (2012) found that the programme was effective and that SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings, and could be used to address some of the unmet demand for treatment.

“SPARX IS AN INTERACTIVE FANTASY GAME DESIGNED TO DELIVER [CBT] FOR THE TREATMENT OF CLINICALLY SIGNIFICANT DEPRESSION. IT UTILISES BOTH FIRST PERSON INSTRUCTION AND A THREE DIMENSIONAL INTERACTIVE GAME IN WHICH THE YOUNG PERSON CHOOSES AN AVATAR AND UNDERTAKES A SERIES OF CHALLENGES TO RESTORE THE BALANCE IN A FANTASY WORLD DOMINATED BY GNATS (GLOOMY NEGATIVE AUTOMATIC THOUGHTS).” Merry et al. (2012)

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5.2 SUMMARY OF LITERATURE: TECHNOLOGY IN MENTAL HEALTH SERVICES The use of technology to support young people in distress, or in mental health services Powell et al (2010) were commissioned by Comic Relief to undertake a scoping literature review and stakeholder consultation exercise about young people’s use of digital technology in relation to their mental health, to underpin Comic Relief’s emerging interest in the field. The review concentrated on three areas:

1. The use of digital technology by young people.

2. The use of digital technology to support young people with a range of mental health problems, and those at risk from suicide or self-harm.

The review points to several caveats in considering the evidence: There is wealth of evidence in relation to ICT use in mental health in an adult population, but fewer papers specifically discussing young people.

The ehealth literature includes reports of a large number of small pilot studies, often ‘initiated by enthusiasts’, and therefore the reviewers warn that these data may not generalise in different contexts, particularly as there is a tendency to write up successful findings and not report unsuccessful activities.

The pace of development of new technologies is such that robust studies in the literature are outdated almost as soon as published. A similar caveat must be applied in this report, as reviews published even in the last year or two would have reviewed literature older than that. Powell et al (2010) used the scoping review to highlight examples of good practice from the evidence, and highlight gaps in domains in a young person’s experience of mental ill health. These are summarised in the table overleaf.

3. The evidence of harm relating to the use of technologies.

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) TREATMENT • Computerised CBT (cCBT) is the ehealth intervention with the most established evidence base for efficacy, with evidence that it is an effective and acceptable tool for treating mild and moderate depression and eating disorders such as bulimia, as well as a tool for self-management.

• The review found limited information specifically relating to cCBT in young people, although studies with interventions such as MoodGYM found moderate benefits for young people with depression. Another study found that completion rates (a key factor in successful outcomes) amongst young people were lower; leading to the recommendation that cCBT may be best delivered to young people with support. Young people showed improvement in both attitudes and behaviours associated with eating disorders following cCBT sessions, providing positive feedback and indication that they might seek further support. That said, positive results may be short term.

• The potential for online delivery of counselling and psychotherapy is now being realised, with implementation at scale through initiatives such as Kooth.com (for young people) and Big White Wall (for general population). The review points to a few studies of online counselling, which show promise. One study with a student population reported a positive effect from disinhibition, the therapeutic benefit of writing, and satisfaction with the service.

a viable service option, especially with those who are typically isolated, or find coming forward a challenge due to stigma.

Other studies highlight the need for caution, with concern about the lack of verbal and non-verbal processes in sessions leading to a concentration on rapport in online sessions as opposed to the accomplishment of tasks. Nevertheless, online counselling appears to be

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) ADJUNCT TO TREATMENT • There is some evidence to support guided self-help (such as bibliotherapy) with therapist initiated telephone or email contact. Telephone contact had the better reported increase in positive outcome compared to email, but the study was from 2006, and this may have shifted with the rapid advancement of social media. Email contact as an adjunct to therapy has shown promise in both a counselling setting, and in work with people with more complex mental health problems. Email as an adjunct might be particularly useful for clients who express a preference to communicate in this way, to those with particularly high anxiety of social situations, and those who are isolated.

• SMS text messaging has shown some promise in supporting individuals during the therapy process, in terms of exploring issues, addressing suicidality, and ‘checking in’ between appointments. SMS technology is much more widely accessible than smartphones. Examples of SMS support is used by Samaritans, TESS Self-harm support and by the WISH Project in Harrow, North London. WISH uses a two question text based tool to assess risk of suicide in its young female clients, and adjusts frequency and urgency of support based on answers.

• Data on the use of therapeutic role play in avatar based computer generated worlds are emerging, with work in counselling, in ADHD support, and in cCBT (Merry et al 2012)

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) PEER SUPPORT • The evidence for peer support in mental health, including for young people has developed over the last few years. Powell et al (2010) call for further research on the efficacy of online peer support and in particular for internet support groups (ISGs), given the number of informal peer support networks that exist and which young people use.

• There is evidence on the acceptability and desirability of these support groups and forums for their users, but less in terms of outcomes. There is also some evidence that virtual communities do not harm the health and social outcomes of their members.

• Online peer support is growing, including in the postdiagnosis phase, and in terms of buddying or mentoring as an adjunct to self-management training. There are advantages, in terms of the willingness of individuals to disclose and discus issues of a sensitive nature, but also disadvantages, such as creating an illusion of privacy, and a limitation on the ability to probe for elaboration and escalate support in crisis.

• The review discusses anecdotal evidence from the development of the ReachOut online community forums, which provides an online forum for young people that is peer moderated by trained volunteers aged 16-25. Users saw the forum as positive, unique and helpful, but little was reported about the impact on stigma or the translation of online discussions into uptake of services offline.

•There is some evidence that online peer support spaces where there is an option to call on the expertise of a clinician or other expert are more accepted.

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) HELP SEEKING • The review reports the reluctance of young people who experience mental health problems to seek support, with only 20% of young people approaching services for assistance. There is a general assumption that technology may assist those who do not seek help to reach out, to services, and to find and utilise self-help/selfmanagement.

•Text messaging has been associated with improved help seeking behaviour, for instance in mass texting of students with details of sources of help and advice.

MONITORING • There is some evidence to suggest that participation in online discussions with peers and use of information sites enables people to build courage to seek treatment and persist with it.

Predictors on online help seeking for suicidal ideation included use of telephone helplines, and not going to offline mental health services.

There is good evidence to support the use of mood trackers and similar means of monitoring symptoms. This could be via text message or using web based tools or applications.

• Online screening tools offered to large populations have been used to ‘find’ students at risk from suicide. Where respondents were given the opportunity to have online dialogue with a counsellor following an assessment, they were three times more likely to attend in person for detailed assessment and treatment than those who did not have that contact. Results showed that internet skills, hours online, demographic and depressive symptoms were not significantly related to online help seeking.

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) EDUCATION • Online information sources are well regarded by young people, particularly when digital products are designed with young people. Research to co-design selfhelp/education sites on student mental health has demonstrated the importance of working with target audiences to define and develop resources.

• One major survey (2009) compared young people’s preferences for a website with self-help books, face to face counselling or mental health services. 71% of people rated books and websites as being helpful, which was more than for mental health service and less than for counselling. Predictors of finding websites useful included older age (1825), belief in help-seeking, less social distance from the vignette presented. Most young people appeared open to the idea of accessing mental health information online, especially for problems considered to be ‘behavioural’. These young people seemed more interested in help seeking generally, and more willing to associate with peers who have mental health problems.

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5.2 SUMMARY OF LITERATURE: PERSPECTIVES ON RISK & VULNERABILITY Perspectives on risk and vulnerability Research indicates that online risks are ‘not radically different in nature or scope than the risks minors have long faced offline, and minors who are most at risk in the offline world continue to be most at risk in the online world’ (Palfrey et al, 2008) Young people using technology do face risks, including from grooming and exploitation, from cyberbullying, sexting, blackmail and the consequences of sharing personal data or betrayal of trust. Most of these have a mental health impact, and indeed have been associated with episodes of suicide and selfharm widely reported in the media. Data from EU Kids Online (Staksrud et al, 2013) suggest for instance that children who use social networking are more likely to encounter online risk, and that those with greater digital competence encounter more risks, not fewer risks; because they undertake a wider range of online activities. Staksrud also reported that digital competence did not reduce the likelihood that children would be upset by online risks. They did however find that children who had public profiles experienced

more risks than those who followed guidelines about maintaining privacy settings. Most reviews suggest that the route to mitigating the risks that young people encounter lies in changing our approach to cybersafety, to focus on the way young people actually understand risk and internet use, as opposed to the way adults often perceive that they do: that even playing violent games can have creative, social and emotional benefits.)

“POLICY CURRENTLY FOCUSES PRIMARILY ON REGULATING THE NEGATIVE EFFECTS OF SNS AND SOCIAL MEDIA, FREQUENTLY FRAMING DIGITAL CITIZENSHIP WITHIN AN ONLINE RISK-MANAGEMENT PARADIGM ... RECONCEPTUALISING THESE CHALLENGES IN TERMS OF EXPANDING YOUNG PEOPLE’S DIGITAL CITIZENSHIP OPENS UP THE POTENTIAL TO MAXIMISE THE WIDE RANGE OF SUBSTANSIVE BENEFITS ASSOCIATED WITH ONLINE COMMUNICATIVE PRACTICES.” Collin et al. (2011)

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5.2 SUMMARY OF LITERATURE: PERSPECTIVES ON RISK & VULNERABILITY Singh et al (2011) call for a reframing of the term vulnerable young people, in terms not just of an individual’s risk taking behaviour or circumstances, but also of the context in which their lives are led. Vulnerability, they argue, is often a function of systemic inequalities woven throughout the system. They suggest that vulnerability could be viewed as:

“…a circumstance young people may experience or are exposed to, as opposed to a concept that they in themselves are. By suggesting they are vulnerable in and of themselves, young people’s individual identities and uniqueness are diminished, and they are homogenised into a definition which does not recognise their individuality as anything other than vulnerable.” (Singh et al, 2011)

Within this framework, there is a recognition that young people facing vulnerability are at risk from poor mental health, and also that these young people might seek to use technology to emphasise their identity, and reduce their risk of vulnerability by using social networking and other services to reduce isolation and structural barriers, and online services to access peer support and treatment. The evidence base on the use of the internet by young people experiencing vulnerability is still sparse, and there is a need for further research which recognises the complexity in young people’s lives, including the way in which they use technology.

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5.3 SUMMARY OF PRACTICE: EXEMPLAR PRACTICE EXAMPLES Exemplar Practice Examples In the past year several useful guides for practitioners have been published. The following is intended to serve as a brief guide for readers who wish to explore the subject in greater detail.

Innovation Labs http://www/innovationlabs.org.uk Innovation Labs is a joint programme between Comic Relief, Paul Hamlyn Foundation, Nominet Trust, Mental Health Foundation and Right Here. The programme worked with young people, service designers, developers and funders to codesign a suite of digital tools that young people would use to assist them with their mental health. Two participative design events were led in 2011, where a design process encouraged the generation of ideas, and then wireframe prototyping of projects. The top projects were then developed as briefs which organisations were invited to bid to develop.

to every project, and the programme board includes and supports young people to participate in the management of the work. The programme is being evaluated as it progresses, and the funders have also enabled the sharing of good practice with all interested parties, via the Innovation Labs website and regular e-bulletins.

Using technologies safely and effectively to promote young peopleâ&#x20AC;&#x2122;s wellbeing: A Better Practice Guide for Services (Young and Well CRC) http://reports.youngandwellcrc. org.au/a-better-practice-guide-forservices/ Published in March 2013, this guide provides a range of examples to assist health, social care and third sector services to use digital technology to support young people with their mental health. The guide summarises evidence, highlights good practice, and suggests top tips for implementation. It covers both both the principles of using technology such as email or forums, and the practical application of specific platforms such as Facebook, or Twitter.

Seven projects have each been awarded ÂŁ50k to develop the projects into sustainable digital tools using a rapid start-up digital innovation model for launch by June 2014. The projects are being delivered by a range of partnerships including statutory organisations, digital agencies, national and local

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5.3 SUMMARY OF PRACTICE: EXEMPLAR PRACTICE EXAMPLES

Participatory Design of evidencebased online youth mental health promotion, prevention, early intervention and treatment (Young and Well CRC) http://www.yawcrc.org.au/knowledgehub/publications Young and Well CRC have produced this guide for applying participatory design principles to the development of digital tools for young people in relation to mental health and well-being. The guide explores the evidence for co-design/ service design approaches and discusses in an accessible format how these methods can be used in practice by youth agencies.

Social Media in Mental Health Practice: Online Network tools for Recovery and Living Well. http://www.leedsandyorkpft.nhs.uk/ professionals/digitalhealthinnovation Social Media in Mental Health Practice is a social media guide for health and social care practitioners working in mental health services. The free ebook gives a broad

overview of key social media that can be used to help people as part of their recovery, using examples from across the UK and beyond.

The role of online and online peer support for young people who self-harm â&#x20AC;&#x201C; Good practice guide. (YouthNet) http://www.youthnet.org/2012/12/ the-role-of-online-and-online-peersupport-for-young-people-who-selfharm/ Youthnet, 42nd Street and Depaul UK were partners in an EU funded project about online support for young people who self-harm. Youthnet collated a good practice guide based on work with partners in the UK, Denmark, Slovenia and Italy. It presents a framework for delivering online peer support to young people who self-harm, linking this back to evidence on stigma, self-stigma and the challenges of working with young people who are self-harming or at risk of self-harm.

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REFERENCES References Bacon, K and Turberville, V (2013) Finding the Digital Edge. Digital Engagement UK. London http:// www.onlineyouthoutreach.co.uk/ downloads/Finding_the_Digital_ Edge.pdf (accessed July 2013) Betton, V and Tomlinson, V (2013) Social Media in Mental Health Practice: Online Network tools for Recovery and Living Well. Leeds and York Partnership NHS Foundation Trust. Leeds. http:// www.leedsandyorkpft.nhs.uk/ professionals/digitalhealthinnovation (accessed July 2013) Boon, V (2013) Innovation Labs Process Evaluation: Dec 2010 – Feb 2012. Innovation Labs. London. http://www.innovationlabs.org. uk/wp-content/uploads/2013/07/ Innovation-Labs-Process-201012-Evaluation-External-Report.pdf (accessed July 2013) Boyd D and Ellison M (2008) Social Network Sites: Definition, History & Scholarship. Journal of ComputerMediated Communication 13:210230. http://onlinelibrary.wiley.com/ doi/10.1111/j.1083-6101.2007.00393.x/ abstract (accessed July 2013)

Burns, JM, Davenport, TA, Christensen, H, Luscombe, GM, Mendoza, JA, Bresnan, A, Blanchard, ME & Hickie, IB, 2013, Game On: Exploring the Impact of Technologies on Young Men’s Mental Health and Wellbeing. Findings from the first Young and Well National Survey. Young and Well Cooperative Research Centre, Melbourne. http://www.yawcrc.org. au/knowledge-hub/publications (accessed July 2013) Campbell, AJ and Robards, F (2013) Using technologies safely and effectively to promote young people’s wellbeing: A Better Practice Guide for Services. NSW Centre for the Advancement of Adolescent Health. Westmead and the Young and Well CRC, Abbotsford, Australia. http://reports. youngandwellcrc.org.au/a-betterpractice-guide-for-services/ (accessed July 2013) Collin, P , Rahilly K, Richarson I, Third A(2011) The Benefits of Social Networking Services: A Literature Review. Young and Well CRC, Melbourne http://www.yawcrc.org.au/ knowledge-hub/publications

(accessed July 2013) Foster, C (2013) Essential Skills for Giving Online Peer Support at YouthNet. Blog. Youthnet. London http://www.youthnet.org/2012/06/ essential-skills-for-giving-onlinepeer-support-at-youthnet/ (accessed July 2013) Hagen, P et al (2012) Participatory Design of evidence-based online youth mental health promotion, intervention and treatment. Young and Well CRC, Melbourne http:// www.yawcrc.org.au/knowledge-hub/ publications (accessed July 2013) Hagen, P, Collin, P, Metcalf, A, Nicholas, M, Rahilly, K, & Swainston, N 2012, Participatory Design of evidence-based online youth mental health promotion, prevention, early intervention and treatment, Young and Well Cooperative Research Centre, Melbourne.ICO (2013) http:// www.yawcrc.org.au/knowledge-hub/ publications (accessed July 2013) Innovations Labs (2013) Labs Innovation Process Evaluation 201012: What We Learnt (blog) http:// www.innovationlabs.org.

uk/2013/07/24/innovation-processlearning/ (accessed July 2013) Johnson, D, Jones, C, Scholes, L & Carras, M 2013. Videogames and Wellbeing, Young and Well Cooperative Research Centre, Melbourne. http://www.yawcrc.org. au/knowledge-hub/publications (accessed July 2013) Livingstone, Sonia and Helsper, Ellen (2013). Children, internet and risk in comparative perspective. Journal of children and media, 7 (1). pp. 1-8. ISSN 1748-2801 http:// eprints.lse.ac.uk/48952/ (accessed July 2013) Livingstone, Sonia, Palmer, Tink and other, contributers (2012). Identifying vulnerable children online and what strategies can help them. UK Safer Internet Centre, London, UK. http://eprints.lse. ac.uk/44222/ (accessed July 2013) Livingstone, Sonia, Ólafsson, Kjartan and Staksrud, Elisabeth (2013)Risky social networking practices among ‘under-age’ users: lessons for evidence-based policy. Journal for computer-mediated communication,

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REFERENCES 18 (3). pp. 303-320. ISSN 10836101http://onlinelibrary.wiley.com/ doi/10.1111/jcc4.12012/pdf (accessed July 2013) Livingstone, Sonia, Kirwil, Lucyna, Ponte, Cristina and Staksrud, Elisabeth (2013) In their own words: what bothers children online? with the EU Kids Online Network. EU Kids Online, London School of Economics & Political Science, London, UK. http://eprints.lse.ac.uk/48357/ (accessed July 2013) Livingstone, Sonia, Haddon, Leslie, Görzig, Anke and Ólafsson, Kjartan (2011). Risks and safety on the internet: the perspective of European children: full findings and policy implications from the EU Kids Online survey of 9-16 year olds and their parents in 25 countries. EU Kids Online, Deliverable D4. EU Kids Online Network, London, UK. http:// eprints.lse.ac.uk/33731/ (accessed July 2013) McGrath, H 2009, Young People and Technology: A review of the current literature, 2nd ed., prepared for The Alannah and Madeline Foundation. Merry J et al (2012) The effectiveness of SPARX, a

computerised self-help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ 2012; 344 :e2598 doi: 10.1136/bmj. e2598 http://www.sparx.org.nz/cdn/ Merry%20et%20al%20(2012)%20 BMJ.pdf (accessed July 2013) Ólafsson, Kjartan, Livingstone, Sonia and Haddon, Leslie (2013). Children’s use of online technologies in Europe : a review of the European evidence base. EU Kids Online, EU Kids Online Network, London, UK http://www. lse.ac.uk/media@lse/research/ EUKidsOnline/Home.aspx (accessed July 2013)

harvard. edu/pubrelease/isttf/ (accessed July 2013) Powell J, Martin S, Sutcliffe P, Todkill D, Gilbert E, Moli P, Sturt J (2010) Young People and Mental Health: The Role of Information and Communication Technology. University of Warwick/ Comic Relief. London. (unpublished but available on request) Princes Trust (2013) Digital Literacy Survey 2013. Princes Trust. London http://www.princestrust.org.uk/about_the_trust/what_ we_do/research/digital_literacy_ research_2013.aspx (accessed July 2013)

Office of the Information Commissioner (2013) Social networking and online forums – when does the DPA apply? London. http://www.ico.org.uk/ for_organisations/data_protection/ topic_guides/online (accessed July 2013

Singh J, Hartup M, Blanchard M, Burns J (2013) Cybersafety and Young People: Negotiating Responsible Digital Citizenship. Young and Well CRC, Melbourne http://www.yawcrc.org.au/knowledgehub/publications (accessed July 2013)

Palfrey J, Sacco D, Boyd D, DeBonis L (2008). Enhancing Child Safety and Online Technologies: Final Report of the Internet Safety Technical Taskforce, Harvard University, Berkman http://cyber.law.

Singh J, Hartup M, Blanchard M, Burns J (2011) Young People and Vulnerability: Reframing Issues and Addressing Challenges. Young and Well CRC, Melbourne. http:// www.yawcrc.org.au/knowledge-hub/

publications (accessed July 2013) Staksrud, Elisabeth, Ólafsson, Kjartan and Livingstone, Sonia (2013) Does the use of social networking sites increase children’s risk of harm? Computers in human behavior, 29 (1). pp. 40-50. ISSN 0747-5632 http://eprints.lse. ac.uk/45016/ (accessed July 2013) The Corner (2012) Pose, Sext, What Happens Next (Leaflet) The Corner. Dundee http://www.thecorner. co.uk/3_Sexting.html Third, A., Richardson, I., Collin, P., Rahilly, K. & Bolzan, N. (2011) Intergenerational Attitudes Towards Social Networking and Cybersafety: A living lab. Cooperative Research Centre for Young People, Technology and Wellbeing. Melbourne. http:// www.yawcrc.org.au/knowledge-hub/ publications (accessed July 2013) Third, A, Spry, D & Locke, K 2013, Enhancing parents’ knowledge and practice of online safety: A research report on an intergenerational ‘Living Lab’ experiment, Young and Well Cooperative Research Centre, Melbourne. http://www.yawcrc.org. au/knowledge-hub/publications (accessed July 2013)

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Young Scot (2013) “Mobile, Internet & Apps Survey”. 634 responses from young people aged 11-26.

Youthnet (2012) The role of online and online peer support for young people who self-harm – Good practice guide. London. http://www. youthnet.org/2012/12/the-role-ofonline-and-online-peer-supportfor-young-people-who-self-harm/ (accessed July 2013) Ofcom Communications Market Report (2012) http://stakeholders. ofcom.org.uk/market-data-research/ market-data/communicationsmarket-reports/cmr12/internet-web/ uk-4.03 Ofcom Communications Market Report Scotland (2012) http:// stakeholders.ofcom.org.uk/ market-data-research/market-data/ communications-market-reports/ cmr12/scotland/ The Carnegie UK Trust. “Across the Divide: Tackling Digital Exclusion in Glasgow” (2013)

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ILLUSTRATIVE MAP OF DIGITAL ASSETS FOR YOUNG PEOPLE’S MENTAL HEALTH. (See appendices for full mapping document.) ABOUT THIS DOCUMENT: The project team collected around fifty examples of services, campaigns and digital assets that were targeted at young people, both in development and in operation. The mapping exercise was not exhaustive. Based on the examples we have identified, we have proposed three ‘activity types’ to base a map of assets in the six key audience areas. What is clear is that many services fit more than one activity type.

In terms of the public service context, the value of online information sources is already well recognised. We present examples which show both mental health specific information and wider youth information which includes mental health, with an idea of enabling discussion about how best to present information and encourage interaction and social sharing by young people of accurate content.

In terms of online services, we have presented examples from NHS, third sector and social enterprise/business sectors, which use digital technology to deliver mental health services, increase young people’s engagement with services, and enable young people to self-manage their mental health problems. Assets in this category are likely to be of particular interest to NHS stakeholders.

Finally, we have sought to connect the audience categories to the ways in which young people use the internet to develop and maintain social capital, explore identity and reflect. These assets will be of interest both in terms of their touch points with those using NHS services, and in terms of understanding how young people are using digital in the way young people of previous generations may have kept paper diaries and passed notes in class.

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PROCESSES CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

CHAPTER 4

THIS SECTION OUTLINES THE METHODS UTILISED IN CONDUCTING BOTH THE DESK BASED RESEARCH AND THE ENGAGEMENT ACTIVITIES CARRIED OUT WITH YOUNG PEOPLE.

OUTCOMES OF CO-DESIGN SESSIONS

CHAPTER 5 DESK RESEARCH FINDINGS

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

READ READ

READ

READ READ READ

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6.1 YOUTH ENGAGEMENT PROCESSES: OVERVIEW Working with local youth groups, we carried out 6 individual case study interviews with carefully selected young people, and 5 group engagement sessions. The sessions were carried out as part of each youth groups programme of events, taking place at their facilities and supported by their group leaders and workers. Due to the sensitive nature of the subject matter, only young people in a well supported environment were approached, and appropriate aftercare measures were put in place.

Fri 21st June: Erskine Music Media Group size: 10 Thurs 25th July: Big ShoutER Group size: 4

We designed a bespoke set of tools for the engagement sessions to facilitate the young people’s involvement. We framed the sessions as mini-design research workshops, splitting the larger groups into two teams and assigning the young people roles The groups we worked with for the (eg. ‘Visualiser’ and ‘Summariser’). engagement sessions are as follows: Each young person was given a sketchbook, to jot down ideas and Mon 17th June: thoughts that they didn’t want to YoMo: Glasgow East’s Youth Empow- make public erment Charity, Dennistoun. Group size: 11 We then led them in a series of activities, which are listed overleaf. Tues 18th June: These were adapted slightly from Active Renfrewshire, Paisley. group to group, and not every Group size: 8 session included every activity. Weds 19th June: GAMH Young Carers, Govan. Group size: 6

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6.2.1 YOUTH ENGAGEMENT PROCESSES: ACTIVITIES The activities first focused on digital media use, then on issues of mental wellbeing. Finally we looked at how the two areas might combine. Activity 1: Digital and social media use A very simple warm up activity in which the young people we asked to pick and match up icons in order to demonstrate which social media sites they used most, and which digital devices they used in order to access them. Activity 2: Understanding social media interactions This activity helped the young people to analyse their use of popular social media sites such as Facebook. It asked them to break down their most recent interactions through a series of questions, helping them to articulate what exactly they were using the sites for, who they were talking to, and the positives and negatives of social media experiences.

Activity 3: Brainstorm on mental health This brainstorm began as a word association game, that encouraging the young people to write down anything that came to mind in relation to the words â&#x20AC;&#x2DC;Mental Healthâ&#x20AC;&#x2122;. The results were clustered into themes and the brainstorm was then directed to discuss various key themes, including: how young people could look after their mental health, who they went to for support and advice, what they felt about the stigma that surrounds mental health, etc. Activity 4: Persona Building The young people were asked to create a character that may need the help of mental health support services, based around a prompt card. This prompt card provided a clue as to their experience of mental health issues. They were asked to consider the characterâ&#x20AC;&#x2122;s interests and social media use, but also their relationships with friends and family, and who they trusted for advice.

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6.2.1 YOUTH ENGAGEMENT PROCESSES: ACTIVITIES Activity 5: Storyboarding Following on from the persona activity, the young people were asked to draw or write a story - in a series of small steps - about their character, in relation to the prompt card hinting at their experience of mental health issues. Activity 6: Problem and Opportunity Identification

Activity 7: Opportunity/Idea Creation Through the use of a specifically designed opportunity card, we helped the young people to create and articulate quick ideas for digital (and otherwise!) support services. They were asked to create ideas for the characterâ&#x20AC;&#x2122;s created in the persona building exercise or discussed during the brainstorm activity.

This activity used a stickering method to help the young people identify the problems surrounding mental health issues and social media use that had arisen during the previous exercises. We then aided them in identifying possible opportunities that could help build ideas for services.

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6.2.2 YOUTH ENGAGEMENT PROCESSES: CO-DESIGN SESSIONS The co-design sessions were attended by a core group of young people who had expressed enthusiasm for the project after participating in one of the initial enagagement sessions. The first session primarily focused on free and imaginative idea generation through games, sketching and visual brainstorming techniques. An entire wall of vibrant service ideas, dreams and thought was created. Much thought was given to the space in which the sessions took place and objects used as props, in order to stimulate the young peopleâ&#x20AC;&#x2122;s imaginations and to maintain a safe, mentally healthy environment.

graphic identities and screen shots demonstrating some of the proposed interactions of these services ideas. These were presented back to the young people at the next session in a mock board meeting. The young people were given roles to play and prompts for how to do so; one was to be, for example, a skeptical commissioner, another a worried parent, yet another an enthusastic young supporter of the idea. This allowed for an imaginative evaluation of the ideas from different perspectives. User journeys were then drafted to further develop how the ideas might work in practice.

This ideas were then categorised into possible services and broader visions. They were evaluated and the favourites selected. Two ideas for services that supported youth mental health were then chosen. Through the use of personas and imagined user journeys, the young people began to imagine exactly how these could work and what the benefits would be. Following this session, project members at Snook created

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6.2.3/4 ENGAGEMENT SESSION RISK MANAGEMENT & LIMITATIONS Risk Management Due to the sensitive nature of the projectâ&#x20AC;&#x2122;s subject manage, stringent risk management was required. Engagement sessions were arranged only with pre-existing youth groups who had previously been involved in similar types of youth engagement projects, and in which the young people were known to be well supported. These youth groups were either a part of the Health Boardâ&#x20AC;&#x2122;s networks or those of Young Scot, who have extensive experience in youth engagement work

Limitations Appropriate aftercare procedures were put in place. All participants were kept fully informed of the research process and gave written consent for their participation and any appearance in photographs. Group leaders and workers were closely liaised with before and after each session. The individual activities were carefully planned, with the focus on positively framed discussion and idea generation. The persona building and storyboarding exercises were only used in groups

where the young people were specifically supported in mental health issues by experienced youth workers, as they have the potential to cause the young person to reflect on negative personal experiences, despite asking them to think about the situations of others. Such activities should only be carried out in the most well supported environments.

The very fact that the young people within the engagement and codesign sessions all attended youth groups meant that completely socially isolated young people would not be engaged with and hence exclude those that would perhaps be most in need of support for mental health through digital means. Finding appropriate and risk managed ways in which to engage with socially isolated young people merits an entire research and design project in its own right, but was not possible in the scope of this project. Thanks to the existing networks of GGC NHS and Young Scot, we were able to approach a broad range of youth groups in order to achieve diversity in our engagement sessions in terms of ethnic background, sexual orientation, physical and learning abilities and beyond. However, timing issues and capacity restrictions meant that we were not able to meet all groups initially contacted and to achieve quite the level of diversity we would have liked. Further work is required to ensure that the true diversity of youth voice is heard as digital assets are developed.

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6.2.5 UTILISATION OF PROJECT BRANDING & SOCIAL MEDIA A clear visual identity was created to generate a feeling of momentum and allow the young people involved to connect with the project. It also allows enables easier dissemination of the project to a wider audience of young people and interested partners. We named the project ‘PROJECT 99’ after the phrase ‘99 problems’, that all young people would be well aware of. It was deemed that a name that didn’t directly relate to mental health was desirable for credibility and stigma related issues. The brand aims to appear energetic and approachable. It aims to be more ‘lifestyle’ than specifically ‘health’ in terms of positioning. The branding has been utilised on the bespoke engagement tools created for our sessions with young people. It it also represented through a specially created project website, blog and twitter stream. The website has a deliberately simple and adaptable aesthetic; not just for ease of reading, but to allow easy adaptation and contiunation, as the project develops. The website has a ‘HELP’ button visible at all times, that will take any distressed young people visiting the site directly to a list of emergency

contacts, as hosted on the Mental Health Foundation website. There is also a ‘quick hide’ button for young people worried about being seen using a mental health related site. It takes them immediately to the home page of a search engine. It is aimed primarily at the young people engaged in the project so far, but has scope beyond this as a means of dissemination for the project outcomes. Crucially, the website also contains a blog and there is an active Project 99 twitter account. In the spirit of the project, they have been created in order to allow the NHS to experiment with direct communications to young people through social media and to create transparency around the project process. The blog and twitter account have not yet been heavily pushed to young audiences, meaning they have a low amount of followers, providing a low risk test bed for such communications to take place. Should the project and branding have scope beyond this initial stage, a social media presence is already in place and ready to be pushed to young people through relevant channels.

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6.3 DESK BASED RESEARCH PROCESSES. This second strand of the project approach explores the existing digital services that provide support for youth mental health.

telephone interviews. We have used this input to present a series of case studies to illustrate the types of approaches that are feasible.

Mental Health Foundation, Snook and Young Scot used their existing networks and knowledge of this field to review publicly available material gained through basic literature searches and use of search engines. We combined this with grey literature provided through our networks, and via input from key stakeholders gained through

The culmination of this research to date is presented in chapter 5 of this report and the mapping document in the appendices. This paper uses an illustrative approach, providing a snapshot and some pointers for further reading. It is not a systematic review of literature, nor a comprehensive mapping of initiatives.

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RECOMMENDATIONS CHAPTER 1 PROJECT OUTLINE

CHAPTER 2 USER CASE STUDIES

CHAPTER 7 RECOMMENDATIONS FROM PROJECT PARTNERS THIS SECTION OUTLINES THE RECOMMENDATIONS MADE BY THE PROJECT PARTNERS AS A RESULT OF THE PREVIOUSLY DETAILED FINDINGS.

CHAPTER 3 INSIGHTS FROM ENGAGEMENT SESSIONS

CHAPTER 4 OUTCOMES OF CO-DESIGN SESSIONS

CHAPTER 5 DESK RESEARCH FINDINGS

CHAPTER 6 RESEARCH PROCESSES

CHAPTER 7 RECOMMENDATIONS

READ READ

READ

READ READ READ

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CHAPTER 7: SUMMARY PROCESS The recommendations made in this chapter have been catergorised into four sections as follows:

1. A co-design approach,

with a framework for on-going engagement with young people is the default for any projects seeking to develop digital assets for youth mental health.

2. GGC NHS should develop

a youth engagement framework to support this on-going engagement, with potential internships for young people.

Within this digital springboard specific areas should focus on supporting individual young people, including:

Emergency 24 hour Instant Messaging tools

1. Service directory 2. Advice directory 3. Tool kit for wellbeing 4. Links to and connections

Empathy tools

Access to forums for group support

Access to tools which help maintain good mental health

Practical day to day tips on managing common mental health problems

with wider services

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CHAPTER 7: SUMMARY WIDER IMPACT 1. GGC NHS should develop an emotional literacy programme as part of educational curriculum.

2. A ‘first responder for mental health’ training scheme should be developed to allow support within schools.

3. A campaign should be

developed through which young people are encouraged and incentivised to find ‘a third space’.

NHS USE OF SOCIAL MEDIA NGS GGC should appoint young people as social media managers for peer related content.

NHS GGC social media strategy should include:

1. Creation of interesting,

2. Find appropriate health

3. Monitor and respond

4. Blog developments in

relevant, engaging content which young people would want to share.

to trends (both positive and negative) with appropriate content.

related and user-generated content to share.

digital asset strategy.

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7. CHAPTER OVERVIEW The following recommendations are drawn from the findings detailed in the previous section of this report and from a resulting co-design workshop with members of GGC NHS and the project partners.

The diverse range of insights we have collected through the research process has allowed us to create a series of recommendations for future mental health support strategies for young people, falling into the following categories: 7.1 Recommendations for development of digital assets 7.2 Wider recommendations 7.3 Recommendations for use of existing social media sites by the NHS

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7. RECOMMENDATIONS: SUSTAINED YOUTH ENGAGEMENT Sustaining a participatory approach All recommendations are made with the view that any subsequent development of digital assets should be carried out in close collaboration with young people through continued use of a codesign based approach. We have made the case for the importance of such processes throughout this report:

Refer to page 12 for a detailed case in favour of a co-design and co-production based approach to health care improvement.

“ ... a Participatory Design approach helps us to develop interventions that are engaging to young people and therefore are more likely to be used, increasing the overall reach and impact of the intervention ... From a political standpoint, the commitment of Participatory Design to participation by users is an assertion of the rights of young people to define their own wellbeing goals and participate in their own care. It is an approach that seeks to effect social change, and builds more equitable relationships between health professionals and young people as key partners in the design process.” (Young and Well CRC, 2012)

It is crucial that youth involvement does not cease at this early stage, but continues throughout the design and development of any digital asset. Additionally, sustained youth input will be valuable even after a digital product has

been produced; frequent re-evaluation and modifications will be required in order to maintain the relevance and effectiveness of any asset. To again cite Young and Well CRC:

“Ongoing involvement by young people throughout the design process increases the feasibility and acceptability of the proposed concepts and ideas and ensures that recommendations generated by young people, and then interpreted by researchers or designers into ‘design proposals’, still effectively reflect young people’s input. Continuous engagement also helps keep pace with the fast-changing uses of technology, mitigating some of the impacts of the inherent time lag of translating research and evaluation findings into practice.”

Such an approach can prove beneficial in a variety of ways, not only to the success of the digital asset being created, but also to the young people involved in the process. As both the literature and the outcomes of this project show, the opportunity to feel that you are helping others plays an important role in a young person’s sense of wellbeing. Providing a creative environment in which young people feel that their opinions are being taken into account - and crucially seeing tangible outcomes as a result - is valuable in

Refer to insights gathered from Greig’s case study on pages 19 and 23, from Jenny’s case study on page 17 and from our engagement sessions on page 65 on the benefits of volunteering and helping others for young people. Refer to page 97 for a discussion of the role of creativity and communal creative activities in boosting self esteem and forming identity.

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7. RECOMMENDATIONS: SUSTAINED YOUTH ENGAGEMENT boosting self-esteem and a sense of purpose; and both literature and the co-design outputs here show the important role creativity has to play selfrealisation and identity formation.

Refer to page 27 of Jenny’s case study.

Jenny’s case study also demonstrates the value that involvement in such youth engagement projects, and becoming involved in mental health support in a professional or peer support context, can have in assisting recovery and self-management.. Participation would also provide the young people with a significant ‘third space’ (a space out with school or home). When structured correctly, involvement in such co-design processes also have significant benefits to a young person’s skill development and professional progression. We therefore recommend the creation of a youth engagement structure by the NHS. The structure would be pyramid in form, beginning with the formation of a diverse collaborative network of schools, and then active youth groups and organisations within the GGC area. GGC NHS already has many links with such groups and should look to strengthen and expand this network. Engagement would begin at this level in a manner similar to the processes and activities outlined in this report. Young people attending these groups who demonstrate an interest would then be invited or elected by their peers to join a specially created youth council. This council would work more closely and extensively with designers and

developers in the both the creation and maintenance of digital assets. A parallel training and development scheme could run in conjunction to this for young people interested in progressing into a career (or simply increasing their knowledge and skill sets) in the fields of mental health support or digital media development. The engagement structure could culminate in an NHS sponsored digital internship programme for interested young people. They would aid in the management and development of digital and social media assets within the NHS, gaining professional experience and a further advanced skill sets. The presence of young people within the NHS and their innate understanding of current digital media trends would prove invaluable in allowing the NHS to bridge the intergenerational gap highlighted in evidence, and utilise digital and social media assets in such ways that would stay current, relevant and attractive to young people.

WE RECOMMEND THE CREATION OF A PROGRESSIVE YOUTH ENGAGEMENT STRUCTURE. IT WOULD INCLUDE A PARALLEL TRAINING & DEVELOPMENT SCHEME FOR YOUNG PEOPLE, CULMINATING WITH THE POSSIBILITY OF A DIGITAL INTERNSHIP WITHIN THE NHS. 130

7. RECOMMENDATIONS: SUSTAINED YOUTH ENGAGEMENT The project partners can cite successful examples of such youth engagement structures within our own bodies of work. >>>

SUCCESSFUL YOUTH ENGAGEMENT PROJECTS The Matter Snook and Young Scot have recently worked together to produce ‘The Matter’. It is a programmes that teaches young people how to research, design and publish a newspaper. A brief from an affiliated organisation or council in the form of an issue-based question is handed over to a temporary enterprise of 6-10 young people They are taken through a series of workshops and provided with The Matter digital platform to manage their research and newspaper deadline. The young people undertake the research themselves, guide by facilitators. The group is then provided with a copy writer and graphic designer that they take control of to deliver their newspaper in time for the final presentation back to their client.

It is a co-creative process that allows organisations to find out what young people think and it offers young people the opportunity to learn some employability skills, increase their engagement in the world and contribute to issues that Matter in society.

Youth Commissioner’s Model The Youth Commissioner’s model, as used by Young Scot, puts young people at the heart of decision making. The Youth Commission on Smoking Prevention (ongoing 2013-2014) and the Youth Commission on Alcohol (2010) have given young people a remit to carry out local investigations and present the findings back to decision makers, in both cases, the Scottish Government.

This model provides a great opportunity to make sure young people’s voices are heard and taken seriously. A similar model could be used by GCC NHS to explore how young people would like to be communicated with through digital media by an organisation such as the NHS. The Digital Creative Modern Apprentice programme gives young people the opportunity to earn a qualification (SCQF) while on placement at a partner organisation on a one year working contract. This can encourage employers to take on young people and have them involved in the digital production of the organisation. However, what we have found is that otherwise inexperienced young people are often more

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7. RECOMMENDATIONS: SUSTAINED YOUTH ENGAGEMENT

SUCCESSFUL YOUTH ENGAGEMENT PROJECTS Right Here

WE RECOMMEND EMPLOYING YOUNG PEOPLE IN AREAS IN WHICH THEY ARE ABLE TO CONTRIBUTE TO THE NHSâ&#x20AC;&#x2122;S DIGITAL OUTPUT.

familiar with social networks and digital technology than many of the established workforce and can have a good impact on the digital skills and culture of these organisations. They quickly become valuable and in some case invaluable assets particularly in cases where there is an element of youth engagement through digital and social channels. We would recommend that GCC NHS considers the possibility of employing young people in areas in which they can affect digital decision making and contribute to the digital output of the NHS.

Mental Health Foundation worked with Comic Relief, Paul Hamlyn Foundation, and Nominet Trust to establish and support Innovation Labs as part of Right Here, a five centre national project to enable young people to be more involved in their mental health support. Right Here has published a range of learning about best practice youth involvement in mental health activities, and the Innovation Labs programme has maintained youth involvement both in strategic grant management of the project, and in the design and delivery of the seven projects under development.

As discussed previously in this report, such a youth engagement and (and in general, a user engagement) centred approach has gained considerable credence nationally and internationally. The effectiveness of the series of recommendations to follow relies on any further developments continuing to utilise a co-design led approach, sustaining close youth involvement throughout.

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7.1 RECOMMENDATIONS: DEVELOPMENT OF DIGITAL ASSETS Overview As the snapshot mapping of existing digital assets demonstrates (see the appendices) there are a wide variety of digital resources already available or currently under development; a great deal more than could be covered in the scope of this study. Many of the services and approaches they provide directly align with the evidence, and with suggestions from the young people and with insights arising from our engagement and codesign sessions.

It is clear that services targeted at young people should work in a similar way. From the information we have gathered, web use in young people seems to be centred around browsing a select few platforms which act as springboards for content and external sites (for the most part these will be social media platforms; the likes of Facebook and YouTube are the most common but there are a variety of others that vary depending on personal preference and social groups). A more organic and flexible approach is required in order to produce sustainable and wide reaching impact.

An on-going intelligence gathering and mapping function could enable NHS GGC to make the best possible use of existing (and developing) services, to benefit from emerging evidence, and avoid duplication of effort.

Refer to page 50 for a discussion of the blurring of the offline and online world.

As the pace of digital innovation and change can outstrip the development and publication of conventional peer reviewed evidence, boards should seek other tools for validation of impact and quality marking, collaborating with existing NHS structures for validating health apps, and working with Scottish Government/NHS24 on validation standards. It is clear both from the youth engagement work within the project and the published evidence that the development of a single stand-alone app or website is unlikely to make significant impact on the digital landscape. Young people move seamlessly between digital and non-digital modalities, and indeed use both simultaneously.

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7.1 RECOMMENDATIONS: DEVELOPMENT OF DIGITAL ASSETS

The recommendations in this segment fall into two strands, which will be preceded by a series of overriding principles that apply to both:

Recommendations for a digital ‘springboard’: In this section (please see 7.1.2) we suggest a series of principles for the creation of an NHS digital ‘springboard’ to be used by young people seeking mental health support. This would include an iterative, usercentred and part crowd-sourced / part curated online directory of available mental health support services as a key component. However, it should be more comprehensive than a simple sign-posting site and act instead as a flexible digital toolkit that young people could mould to meet their individual requirements. Recommendations for individual digital assets: In this section (please see 7.1.3) we present recommendations for the kinds of digital mental health support assets this active service directory and toolkit should contain. Some may be existing assets that users could be directed to, or could be purchased or funded by the NHS. There are also further concepts the NHS may wish to consider developing.

In keeping with the commitment to co-design and youth involvement throughout, we draw readers attention to the fact that these recommendations are based on the discussions we had with the groups we reached. We would urge further testing and scoping of ideas with young people in Glasgow to ensure future developments remain closely aligned with young people’s needs and priorities in the target audiences sought.

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7.1 RECOMMENDATIONS: KEY OVERRIDING PRINCIPLES Prior to detailing sections 7.1.2 and 7.1.3, we suggest some overriding principles that are relevant to both sets of recommendations:

Problem-Sharing There was a consensus amongst the young people that we worked with that the ability to understand, express and share problems and emotions appropriately and constructively is crucial to mental wellbeing. It was generally understood that this would not necessarily prevent the onset of mental illness, but that such an ability was necessary for positive selfmanagement. Four basic steps to wellbeing emerged and the subsequent suggestions they made for support services could be seen to align to these. This is of course a simplistic and broad approach, but is useful in contextualising any planned digital assets and in illustrating a key principle; A digital strategy to supporting mental health must take into account this desire for holistic and long term support.

FOUR STEPS TO WELLBEING

Help young people to express, understand and contextualise their emotions and problems.

Help young people to share these emotions and problems in a constructive, supported way.

As outlined in the insights derived from our co-design sessions. See page 84.

Help young people to manage or work through their own problems and emotions; to get the appropriate support to achieve this; and to encourage them to help others to do the same.

To help young people to maintain and promote mental wellbeing.

It must also recognise that an approach to mental health support is perhaps as much about the management/self-management of emotions and â&#x20AC;&#x2DC;distressâ&#x20AC;&#x2122; as it is about the management and understanding of mental illness.

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7.1 KEY PRINCIPLES: POSITIVE FRAMING / WELLBEING OF OTHERS

Refer to page to insights gathered from Greig’s case study on page 22 for a discussion of the ingrained negative framing in young people, and to page 63 for discussion of need for positive framing in mental health support.

Positive Framing

The Wellbeing of Friends and Family

Building from the previous point, we would in fact suggest that any new digital assets be developed as mainstream assets targeting all young people, ensuring that those who do experience distress or mental ill health are able to access and use them. Digital innovation should be equality impact assessed to ensure that the approach works with those at particular risk of mental ill health. A universal approach can also include measures to address particular groups. Whilst we did not work with young people within CAMHS settings, work in other parts of the UK has developed digital assets to positively support recovery and selfmanagement in these populations.

There should be more encouragement and recognition of young peoples’ natural tendency to look out for the wellbeing of their friends and family. Young people are often caring for the mental health of others without even realising fully that this is what they are doing. They should be provided with the proper support and resources so that they might do this to maximum effectiveness and safeguard their own wellbeing at the same time. Digital peer support and communities of interest have potential as a further option in this regard.

The focus on wellbeing for everyone was important in the youth groups we worked with. There was a sense of the communal aspect of mental health. There was a tendency to discuss mental health in relation to others; and recognise that individual’s mental health is affected by - and has a profound influence on - family, friends and wider social circles.

Therefore, it may be that some young people that are hard to reach in terms of mental health support can only be accessed through concerned friends and peers, especially where family relationships may be complex, and trusted adults not available. There is potential to link development in this regard to peer support principles, as well as to reach young people who explore solutions to their own concerns by seeking information for ‘friends’.

IT MAY BE THAT SOME YOUNG PEOPLE THAT ARE HARD TO REACH IN TERMS OF MENTAL HEALTH SUPPORT CAN BE ACCESSED THROUGH CONCERNED FRIENDS AND PEERS.

Refer to Ben’s case study on pages 43 and 47 for a discussion of peer support, and to a discussion on the importance of emotional openness in social networks in Lisa’s case study, page 41. See pages 65 and 105 for further discussion of peer support. Refer to Support2 idea on page 79 and insights gathered from codesign sessions on page 82 ...

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7.1 KEY PRINCIPLES: WIDER CAMPAIGNING / MESSAGES OF PROGRESSION Wider Mental Health Campaigning

Refer to insights gathered from Greig’s case study on page 22, and page 63 for insights from engagement sessions, for a further discussion of the level of expertise in mental health matters amongst some young people with diagnosed mental health problems.

From our work with young people there was a real appetite and ability to discuss and promote mental wellbeing in a very mature fashion. In general, the young people that were most aware of the need to take active care of their own mental health were those that had already been diagnosed with a mental illness / condition. That is not to say that some of the other participants weren’t taking very good care of their mental health; only that they weren’t doing it consciously. There is scope to build a campaigning approach to mental health awareness amongst young people, drawing on successful online campaigns such as ‘It Gets Better’ and the Butterfly Project, using young people’s idealism and media literacy to develop multimedia approaches that peers will use. Positive messages that emphasise and celebrate the tools young people already use daily to manage challenges could connect to broader anti-stigma campaigning and online communities of interest. It seems likely that the renewed ‘see me’ programme being managed by Mental Health Foundation and SAMH will have the opportunity to engage the wider movement of young people in co-design and delivering innovative messages to young people using digital tools.

The idea of recovery as a journey is a key message across all age groups when discussing mental health. Young people are particularly open to the idea of ‘progress’ and change over time. Therefore, it may be appropriate to emphasise messages of progression and improvement when framing mental health issues for young people. This fits well with the promotion of personal recovery stories by peers who are a little older, to show young people in current distress that progress can come quickly. YouthNet for instance uses older young people as moderators on TheSite specifically because they are through their difficulties, but still immediately relevant to young people. Care should also be taken to ensure young people are aware of the consequences of sharing publicly details of their mental health in terms of managing their digital footprint in the future, given how rapidly their feelings can change.

‘Progression’ as a Message to Young People

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7.1 KEY PRINCIPLES: AESTHETICS & FUNCTIONALITY OF DIGITAL ASSETS Aesthetics of Digital Assets

Refer to the Button Wall concept on page 78 and insights gathered from the co-design sessions on page 83 for young peopleâ&#x20AC;&#x2122;s thoughts on the importance of aesthetics in creating a positive digital space.

Any digital asset created should have distinct, interesting and beautiful identity and ethos, and clear expectations for use and behaviour. It is important to set the mood and personality of a digital space as carefully as that of a physical space. When a digital space is bland and without clear rules and aims, its identity becomes solely defined by a critical mass of users. Whilst this may create positive results, it also allows negative behaviours to push to the fore unchecked: Askfm is a worst case example of this. The more specific a sites identity however, the narrower the range of people it will appeal to; hence the need for a whole range of digital assets, rather than one catch-all site.

Funtionality of Digital Assets: Active vs Passive Use The ways in which young people will interact with any one digital asset will vary greatly. However, particularly in relation to social media, use patterns can be loosely defined as being more passive or more active. Active users (or people going through a phase of more active behaviour) will generate a lot of content, participate in and possibly lead any online conversations and engage with a wide range of the assets functionalities. More passive users will simply browse this generated content and are unlikely

to generate their own. Any digital assets created should allow both kinds of user to benefit from the service. However, active, supported use of and engagement with an asset should be encouraged; there is an important shift in going from passively browsing mental health related content to taking active steps to self-manage wellbeing or actively asking for (or giving) support. This is a key point in consideration of impact measurement, where consideration should be given to assessing the benefits of passive engagement.

DIGITAL ASSETS SHOULD HAVE DISTINCT, AND BEAUTIFUL IDENTITIES. IT IS IMPORTANT TO SET THE MOOD AND PERSONALITY OF A DIGITAL SPACE AS CAREFULLY AS THAT OF A PHYSICAL SPACE.

Refer to insights from Greigâ&#x20AC;&#x2122;s case study on page 21, and insights gathered from the engagement sessions on page 55, for a discussion of active vs. passive use of digital & social media.

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7.1 KEY PRINCIPLES: AESTHETICS & FUNCTIONALITY OF DIGITAL ASSETS External Links and Support

Refer to pages 23 of insights form Greig’s case study for discussion of importance of offline support groups and of the ‘third space’.

The importance of also discussing mental wellbeing related issues and receiving support in an offline environment should be encouraged and there should be clear links to offline services available. Digital assets, including online peer support, can be key in encouraging young people to seek help. Tools such as DocReady, the first Innovation Labs project to launch, can assist with planning appointments and managing expectations. One of the strengths of internet based mental health support is the protection felt from the sense of anonymity; vulnerable (or otherwise) young people are able to find information privately and express themselves in ways they may not feel confident doing in an environment where they are known. However, a reliance on digital media alone as a means to self-realisation, support and social interactions was felt by the young people we worked with to be insufficient for a prolonged sense of wellbeing. Users should be encouraged and provided with the information that will allow them to make best use of NHS offline support services and those of relevant third sector groups. Ideally this would also work vice versa, with offline NHS services helping young people to manage their online behaviour. Online and offline services should complement each other, rather than one being seen as a replacement or addition to the other.

A person’s online life should be part of their assessment on referral to CAMHS or other services, with support given to both positively managing problematic online activities and harnessing the benefits of helpful online activity in both inpatient and outpatient settings. This relies on clinical staff being able to undertake these assessments and implement activities in care planning.

ONLINE AND OFFLINE SERVICES SHOULD COMPLEMENT EACH OTHER, RATHER THAN ONE BEING SEEN AS A REPLACEMENT TO THE OTHER. ONLINE BEHAVIOURS NEED TO BE MANAGED AS MUCH AS OFFLINE BEHAVIOURS.

Refer to page 50 for discussion of blurring of young people’s online and offline world’s.

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7.1 KEY PRINCIPLES: EMERGENCY CONTACTS / AGE GUIDELINES / HUMOUR

Refer to insights gathered from codesign sessions on page 83 for young people’s ideas on Emergency Instant messaging and the importance of humour.

Emergency Contacts

Age and Maturity Guidelines

Any digital asset created must have emergency contact options clearly available for those who are in distress, or supporting those who are. There is also a clear desire amongst young people for an emergency instant messaging service to complement the phone lines and drop in options provided by organisations such as the Samaritans.

Not being patronised was a key concern of the young people we worked with. When thinking about target age groups, there was not a huge deal of difference in our sessions between the 15 years olds and the 21 year olds in terms of their awareness of mental health issues and ability to discuss these. We would therefore recommend that any work be targeted at the older end of any age bracket or even that age would not be a key concern, favouring instead individual circumstance and emotional maturity.

‘Humour’ as a Support Tool Humour, used appropriately, is a powerful tool. There was a sense of frustration amongst many of the young people with recognised mental health problems that issues surrounding mental health were either addressed too delicately and seriously / clinically or with ignorant insensitivity. The young people we worked with felt that a well-informed, humorous approach would be favourable; careful co-design would be required in order to gauge this. It is a case of humour being used as a tool to enable young people to make light of their own situation in a constructive way in order to better cope with it and to share it; simultaneously insensitive jokes need to be called out as unacceptable.

It is clear that absolute age boundaries are not helpful, and in wider discussions with stakeholders, it is clear that both younger young people, and older young people outwith the ‘traditional’ secondary school age bracket can be missed. It was outwith the scope of this project to investigate the use of digital assets in mental health for primary aged children, but this would be a key area for further exploration, given that whilst younger young people will seek information, and assets for teenagers may not be appropriate for younger children, however mature.

Refer to insights gathered from Jenny’s case study and the engagement sessions on page 64 for young people’s concerns as regards feeling patronised / not taken seriously...

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7.1.2 RECOMMENDATIONS FOR A ‘DIGITAL SPRINGBOARD’ Central to our recommendations is the concept of a digital platform to enable young people to access a range of mental health assets. This could include an iterative, user-centred and part crowd-sourced / part curated online directory of available mental health support services. It was clear though, that such a platform should be more comprehensive than a simple signposting site and act instead as a flexible digital toolkit that young people could use in a variety of ways to meet their individual requirements. The platform would be aimed at all young people, not only those in distress or with a recognised mental health problem. The specificity for young people, and the universal targeting of the platform would differentiate this from Project Ginsberg, although there could be commonality in approach and shared assets or tools if appropriate. Equally, the use of APIs might enable other assets like ALISS to provided content. There are several examples of service directory development in current use. WellHappy in NHS London, and WhereToGoFor in Brighton and Hove both have listings for assets in a specific local area, and would be useful examples to study, and potentially collaborate with. Rating systems are challenging when rating public services, and organisations such as Patient Opinion might be useful partners to consider in terms of enabling rating and reviewing within appropriate boundaries. Finally, work by NHS Tayside on Need2Talk shows that a small amount of time from NHS staff can maintain a digital service without large capacity concerns. NHS GGC should be aware of the future developments planned for Breathing Space and other ehealth initiatives in Scotland in this regard, as well as databases such as ALISS. There is an on-going question as to whether the NHS and public service should seek to duplicate the offer of third sector providers, or whether these providers have sought to use multimedia and social media to connect to young people when the NHS is not. Key examples such as TheSite, SelfHarm.co.uk and Life.Live It show the value of multimedia content.

A DIGITAL SPRINGBOARD (OR GATEWAY) CONSISTING ITERATIVE, USER-CENTRED AND IN PART USERGENERATED CONTENT SHOULD BE DEVELOPED. IT SHOULD FOCUS ON SUPPORTING MENTAL WELLBEING (IE. NOT SOLELY ON MENTAL HEALTH ISSUES). THE PLATFORM SHOULD INCORPORATE A DIRECTORY OF USEFUL SERVICES, BUT GO BEYOND SIMPLY ACTING AS A SIGNPOSTING SITE, ALSO PROVIDING A FLEXIBLE DIGITAL TOOLKIT FOR YOUNG PEOPLE.

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7.1.2 DIGITAL SPRINGBOARD: PHASE 1: SERVICE DIRECTORY The aims of this â&#x20AC;&#x2DC;springboardâ&#x20AC;&#x2122; can be best envisioned in four phases, based on discussions with young people in the project sessions.

PHASE 1: SERVICE DIRECTORY PHASE 2: ADVICE DIRECTORY PHASE 3: TOOLKIT FOR WELLBEING PHASE 4: LINKS & CONNECTIONS TO WIDER SERVICES. These four phases could be developed simultaneously if possible, but also allow for a staggered approach. This staggered approach is perhaps more desirable in regards to the flexibility it offers. Building in this agile way would allow for greater responsiveness to emerging use patterns.

PHASE 1: SERVICE DIRECTORY The creation of a reliable and officially approved directory of both online and offline support services is key. There are a wealth of resources available that are lost in the noise and no reliable guide to test their quality, effectiveness and safety. Initially, we recommend this directory would be curated and reviewed by mental health experts. This would create a base of approved resources for all aspects of mental health support and the general promotion of mental wellbeing; such as, websites, forums, apps, social media streams as well as a broad selection of offline services. Ideally, this initial curation would also include resources (and reviews of these) suggested by young people with lived experience in a coproduced stage of development. Crucially, the service users could then begin to add to the directory once live. This will ensure the directory remains up to date and relevant. Users could offer their reviews of the services within the directory and suggestions for new resources to be added. These suggested additions by users would need to be moderated. Ideally this would be done officially by a mental health expert. However, the feasibility of this would depend on the scale of user activity. If the directory were to get a large amount of traffic, it may be that the amount of expert moderators needed to respond quickly

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7.1.2 DIGITAL SPRINGBOARD: PHASE 2: ADVICE DIRECTORY PHASE 2: ADVICE DIRECTORY

Refer to insights drawn from Greigâ&#x20AC;&#x2122;s case study on page 21 in regards to the problem of information overload. Also refer to page 16 for considerations for young people with dyslexia.

enough to keep the directory current would not be economically viable. In this instance, user-led moderation could be considered. In order to make this as low-risk an option as possible, the service directory would need to be framed correctly, with a clear identity, ethos and code of expected behaviours (as outlined in the principles in the previous section.) The kinds of services being suggested as effective would also provide key insights into the attitudes and needs of young people and help to detect trends (as would any reviews given of the directory entries.) The ways in which users could search through the directory would be vital to its success. In depth research would need to be conducted to understand the kinds of search terms young people are using (and not using) in order to find information about mental wellbeing. New ways of thinking may be required in helping young people to find the content they need; it may be that searches need to be based more on emotions or specific situations than given mental illnesses, conditions or symptoms. A tool (or tools) may also be required that helps young people to define exactly what it is that they are searching for. Careful consideration would of course also need to be given for the ways in which the search results were displayed and filtered. Long lists of information can be off putting and difficult to process.

An extension of the service directory as described in phase 1 could be realised through the creation of a separate directory of advice, practical tips and inspiration for maintaining mental wellbeing and managing mental health problems. Many of the services the young people would discover through the service directory would provide them with this kind of information. However, creating a central, easy to navigate directory would be extremely valuable; again, this would be part expert curated and part user generated with appropriate moderation strategies. A step would be deleted in trying to find answers to quick queries and information browsing. It should follow the same principles and processes as the service directory; again, the balance of expert and user generated content is key. The advice and tips should come in a variety of audio-visual formats and be quick and easy to digest and, crucially, to share. Video clips, short quotes with attractive images, songs and inspiring talks are likely to be disseminated to young people through other forms of social media (Facebook and Twitter in particular) and hence reach a wider audience.

Refer to the young peopleâ&#x20AC;&#x2122;s ideas on page 75 and in particular the Button Wall and Support2 concepts on pages 76 and 79, as a illustration of the importance of both expert curated and user-generated advice and tips to young people in regards to mental health support.

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7.1.2 DIGITAL SPRINGBOARD: PHASE 3: TOOLKIT FOR WELLBEING PHASE 3:TOOLKIT FOR WELLBEING

Refer to page 76 for a description of the young people’s ‘Button Wall’ concept.

Once the directories are in place, more active use of the ‘springboard’ can be encouraged. Users would be able to collect and store the sites, forums, apps, tips and advice as widgets and information streams to return to, creating their own unique ‘toolkit’. By information streams, we are not simply implying that the content gathered would be stored in a chronological, linear “wall” like arrangement (as is the case with many digital and social media platforms). More intuitive ways of storing, grouping and searching for information is required so that users may shape their ‘toolkit’ to their specific needs. The ‘Button Wall’ concept devised by the young people in our co-design sessions provides an interesting starting point in conceiving ways in which this could be done. More co-design, prototyping and user-testing is however required to establish how exactly these streams could work; different kinds of streams may well be required depending on the user’s situation and reasons for using the ‘toolkit’. Advice should be given and parameters for use should be put in place in order for the ‘toolkit’ to become the most effective self-management tool possible. Users could be led through suggestions and helped to work out (through cleverly designed questions) what kinds of tools and advice would be useful for a given situation. There could even be a variety of ready-made ‘skeleton’ templates available, designed for

different user groups and which the young user could then add to or detract from as works for them. These templates should give a sense of structure and progression; the four basic steps for wellbeing outlined at the beginning of this section could provide a base for this structure, with suggestions of tools and advice provided for each step. Users of the toolkit should also be prompted to reflect on their use process at regular intervals and encouraged to evaluate its effectiveness. We recognise the possibility for addictive behaviour to develop in the use of digital and social media; it is easy to become stuck in habitual use patterns that may not have the most long term positive effect on mental wellbeing. Leading questions would prompt users to think about the exact ways in which they are using any tools and advice, if they are actioning positive behaviours on- and offline as a result of using the toolkit, and encourage them to reflect on and monitor their mood and sense of general wellbeing. Importantly, users would be asked to consider if they are managing to maintain positive mental wellbeing without further support. Clear direction and encouragement to contact offline NHS and third sector support services would be provided for those who feel they are struggling to cope with self-management. Further to this, there

Refer to page 52 for a discussion of excessive use of social media amongst young people.

Refer to insights drawn from Jenny’s case study on page 33 and Greig’s case study on page 23 for a discussion of the importance of sustained background support and ‘mini check ups’ for young people with mental health oproblems.

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7.1.2 DIGITAL SPRINGBOARD: PHASE 4: CONNECTIONS TO WIDER SERVICES PHASE 4: CONNECTIONS TO WIDER SERVICES is great potential for the toolkit to join up with wider NHS services in more concrete fashion, as will be outlined in the explanation of phase 4.

Refer to insights from Greig’s case study on page 21, and insights gathered from the engagement sessions on page 55 for a discussion of active vs. passive use of digital & social media.

This phase assumes an active use pattern and is deliberate in doing so; as discussed in the previous section, moving from more passive information browsing to active self-management is an important shift. However, it is also important that benefits can be derived from more passive use. There may be many users who don’t feel ready or even the need to take more active steps to self-management; there may be users who simply wouldn’t intuitively use or feel uncomfortable using digital media in this sense and will have their own means of selfmanagement. To this end, it should be possible for users to browse example ‘toolkits’ without actively using their own. There should also be the possibility for users to anonymously share their own toolkits and tips (after moderation). The sharing of content is the crux of any thriving social media platform and as we have seen, the sense of helping and sharing advice with others is beneficial to wellbeing.

In addition to the inclusion of offline NHS and third sector services in the service directory (and the opportunity for users to review and recommend these services) there is potential for the development of direct connections with wider service provision. We would suggest that such connections will be important in ensuring the long term success of any digital asset developed. Online assets should not be seen in isolation from offline ones, in much the same way as a young person’s online behaviour should not be viewed as distinct from their offline life. As a bank of reliable digital tools builds up, a number of these could become points of interface with GPs, counsellors or CAMHS team members, or even additions to prescribed treatments. Advanced mood trackers and emotion management tools, story sharing and medication logs immediately stand out as possible candidates, but this is by no means represents an exhaustive list. Coordination with a service such as ‘Doc Ready’ - the remit of which is to prepare young people affected by mental health issues to make the best possible use of an upcoming consultation with their GP could also prove extremely valuable in this regard.

Refer to pages 23 of insights form Greig’s case study for discussion of importance of offline support groups and of the ‘third space’ ...

Refer to page 17 of the mapping document in the appendices for further explanation of the Doc Ready service.

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7.1.2 DIGITAL SPRINGBOARD: PHASE 4: CONNECTIONS TO WIDER SERVICES PHASE 4: CONNECTIONS TO WIDER SERVICES A well designed digital toolkit could provide an important ‘touchpoint’ and sense of support and structure before and in between appointments for young people within the mental health system. It could also aid in the joining up of the different NHS services that a person uses. As we have seen from the case studies contained within this report, connections between different arms of service provision are not as effective for some users as they would expect and can cause problems. Refer to pages 25 and 31 of Jenny’s case study for a discussion of the problems of disconnect in NHS services.

Refer to insights gathered from codesign sessions on page 83 for young people’s ideas on Emergency Instant messaging

As should be the case with any digital asset created, emergency contact options to services such as the Samaritans should be very easy to find for those in distress. Additionally, there was a desire from some of the young people we worked with for an online mental health specific ‘NHS 24’ type service that was not an emergency contact, but that allowed you to send messages asking questions or for advice at any time. This could of course be a costly service to run and unlikely that instant responses would be possible, though low cost examples within the NHS, such as NHS Tayside Cool2Talk do exist. The effectiveness of such a service would therefore rely on the setting of clear parameters of use and user expectations; it should be made very clear who would be responding and within what timeframe, with emphasis placed upon the fact that the service should not be used for emergency queries.

Finally, we suggest a linking with wider cultural, sports and special interest groups. As has been discussed in the findings section of the report, self-realisation through interests away from home and educational spaces is very important in the well-being of young people. The ‘springboard’ should demonstrate this importance in imaginative ways and encourage users to join such groups. It could provide information on local groups and facilities and perhaps incorporate some kind of incentive scheme or subsidy program. Cultural organisations running arts (or other such) projects specifically related to mental health and self-realisation could also use the ‘springboard’ as a platform to advertise for participants and proposals, or to run competitions and online exhibitions.

Refer to page 97 of the literature study for a discussion of the importance of creativity and cultural activities in identity formation in young people.

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7.1.3 RECOMMENDATIONS FOR INDIVIDUAL DIGITAL ASSETS Recommendations for individual digital assets In this section we present recommendations for the kinds of digital mental health support assets that could be included in or hosted on a ‘digital springboard’ platform Some may be existing assets that users could be directed to, or could be purchased or funded by the NHS. There are also further concepts the NHS may wish to consider developing themselves.

An imaginative, multimedia ‘moodtracker’ / tool for expressing and understanding mood and emotions There is a clear need for a ‘moodtracker’ type tool that goes beyond recording emotions and states of mind in numerical or ‘sliding scale’ form. For the young people we worked with, the subtlety emotions were far better expressed and realised through images, animations and video clips, music, quotes from literature and poetry, and stories. An effective tool would ask young users to select and store such content in order to express their emotional state as richly as possible, but also prompt them to reflect on what they had chosen and to work out why they had done so.

Refer to the young people’s Button Wall concept on page 76.

Such a tool has great potential for linking with services provided by GPs, counsellors and CAMHS teams. In this case - particularly in regards to the tight timeframe GP appointments are governed by - it would be important that such a tool would prompt young users prior to an appointment to filter through and select the content they feel will be most useful to express their state of mind, and to work out how they could explain this to someone else. In lengthier counselling sessions, it may be feasible and advantageous to work through more of the content in greater detail. For more ideas on how such a tool could work, we refer you back to the ‘Button Wall’ concept generated during our co-design sessions. Mood trackers and recovery journaling tools have consistently been identified by young people as

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7.1.3 INDIVIDUAL DIGITAL ASSETS: ONLINE SUPPORT COMMUNITIES digital assets they would wish to use. My Journey is an android app already available for use by young people in touch with early intervention services. Within the Innovation labs projects two mood tracker/metrics assets are being developed. MiniMe will target young people experiencing mental health problems, enabling them to record their moods and relate these to events with a view to supporting recovery through developing insight. Mind’s Eye is being developed by MindApples, as a mood tracker with a social dimension, aimed at a general audience of young people who want to mentor their moods and connect with feelings.

Online support communities

Refer to the young people’s Support2 concept on page 79.

Online communities centred on mental health issues exist in abundance and thanks to the anonymity and solidarity they offer, vulnerable young people are often able to discuss and find support for issues that they otherwise might not offline. Users of informal online peer support communities often report their benefits, but there are on-going concerns that unmonitored communities can become detrimental to a young person’s wellbeing. There is certainly a need to better understand the dynamics of pro-ana and other forums that promote eating disordered behaviours or self-harm. There was a desire amongst some of the young people we worked with) for properly controlled

and monitored forum environments, that allow young people to share advice, stories and support amongst themselves, but also to receive expert input and guidance. Forum discussions could be monitored by professionals, who would offer official advice on the forum topic and respond to individual comments. They would essentially act as discussion invigilators, looking out for both the general mood of the discussions and for the wellbeing of the individual contributors. They would have the power to hide inappropriate comments and to contact any users they become concerned about through means of a private message. They would also be contactable for any users that become distressed or uncomfortable with comments made in the forum. Such professional involvement could prove costly, so again, the effectiveness of such a service would depend on the correct managing of users’ expectations of the level of professional involvement, but also on fostering a positive forum environment that promotes self-regulation. There could, for example, be allotted times at which users can ask questions directly to a mental health professional; at all other times their involvement would be far more ‘handsoff’, perhaps only acting only if alerted to something by forum members. Forum themes should be framed in a positive manner and clear parameters set for the expected behaviour of users. Each user could be asked to set trigger warnings and appropriate trigger filters would

Refer to pages 69 and 108 for a discussion of young people’s self management of risk in relation to social media.

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7.1.3 INDIVIDUAL DIGITAL ASSETS: ONLINE SUPPORT COMMUNITIES need to be in place. Users would be encouraged to report anything inappropriate or negative to the professional moderator and to be extremely mindful of their own and each other’s wellbeing. More careful research and co-design would be needed to identify ways in which to foster the most positive forum environment possible, but, as was suggested by a young person in our core codesign team, the key to this may lie in creating a clear, beautiful and positive identity for the forum space and its ethos.

Refer to the mapping document in the appendices for more detail on managed mental health forums already in existence, such as Big White Wall.

As has been discussed previously in the report through the explanation of the young people’s ‘Support Squared’ idea, it is a natural instinct for young people to seek to build friendships with those that they feel they connect with on certain issues. From this instinct comes the desire to be able to talk to others they might find on a forum on a one to one basis. Private messaging between forum users is not, however a function that we would recommend, due to all manner of problems with risk. Users should be asked not to give out email addresses and personal details, and this need to be monitored by the discussion invigilator. Instead, forum users actively seeking friendship should be encouraged to attend local offline community and support groups. Managed mental health forums for young people, and the general public do exist. Big White Wall provides a paid for/bought in by local NHS moderated space for self-expression and support. TheSite offers an online peer support environment, and YouthNet collaborated with

European partners to develop best practice guidelines for providing online peer support for young people who self-harm. Finally, the new BeatBullying platform MindFull combines elements of peers support with online counselling in a managed online space for young people.

Services specifically aimed at young people supporting other people with mental health problems This could include a host of services, including story sharing, forums, tips and advice on what best to say and do in different situations delivered through various imaginative and interesting means, etc. What we would like to emphasise through this recommendation, however, is the importance of framing a digital asset in this way. A huge number of young people, who may not be experiencing mental health problems of their own, are acting as support for those who are, often without fully realising that this is what they are doing. It is important that this is recognised and that they are provided with a space that will allow them to do this most effectively, but also allows them to vent concerns, and encourages them to look out for their own mental wellbeing whilst bearing another’s burden. As mentioned previously in the overriding recommendations at the beginning of this section, it may be that some young people, that are difficult for mental health support services to reach for a host of reasons, can only be accessed via concerned friends and

Refer to the young people’s Support2 idea on page 79. Refer to Ben’s case study on pages 43 and 47 for a discussion of peer support, and to a discussion on the importance of emotional openness in social networks in Lisa’s case study, page 41. See pages 65 and 105 for further discussion of peer support.

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7.1.3 INDIVIDUAL DIGITAL ASSETS: EMERGENCY INSTANT MESSAGING and peers. Equally, providing young people with the premise that they are seeking support for a friend rather than themselves may allow for greater engagement.

Emergency 24 hour Instant Messaging service for people in distress

Refer to insights gathered from codesign sessions on page 83 for young people’s ideas on Emergency Instant messaging

This would act as an addition to the phone lines and drop in options provided by organisations such as the Samaritans. Young people, as digital natives, are very much at home communicating via instant messaging and online chat functions. For some vulnerable young people experiencing distress this would be a far more comfortable and intuitive option than a telephone conversation; some may even feel an inability to call for help. This would of course require a great deal of training and for infrastructure to be put in place, but could be crucial. We also recommend that training offered in terms of suicide prevention and mental health first aid should include the use of social media and IM to interact with peers and to conduct suicide prevention interventions.

Dissemination of advice on how to maintain positive mental health The young people we worked with found it difficult to name positive, everyday measures that would allow them to look after their mental health. This was in stark contrast to maintaining physical health, which all could discuss with confidence. Advice needs to be compiled and promoted that will encourage the day to day maintenance of good mental health. The most comprehensive and ambitious means to do so would be through an extensive campaign that would extend beyond a single digital online asset to the school curriculum, and would also attract opportunities for private companies and third sector groups. ‘see me’ produced and activities pack for schools and youth groups which was launched in 2012 and the Glasgow Anti-Stigma Partnership has run sessions in schools in Glasgow since 2009. There may be scope to build on these sessions with a mental health improvement message.

Refer to page 63 for discussion of need for positive framing in mental health support.

The power of rapid information dissemination online could be harnessed with a carefully thought through digital campaign, that targeted social media sites such as Facebook, YouTube and Twitter. This would need to utilise a range of techniques, mediums, styles (and most likely celebrity endorsements) that tied in with internet trends amongst young people at the time. Crucially, the information would need to be in a format that young people could adapt and share easily and may require a well-publicised event to

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7.1.3 INDIVIDUAL DIGITAL ASSETS: PRACTICAL TIPS / EMPATHY TOOLS act to stimulate interest. The campaign could also encourage active user participation in order to create sustained impact; users could, for example, be encouraged to share a positive thought, image or action each day in a social media stream, or send a positive message to a friend.

Practical, day-to-day tips for self-management of common mental health problems

Refer to page 64 for a discussion of a favouring of self help amongst some young people. See page 83 for the young people’s ideas on self management

This is in close relation to the previous recommendation, but specifically targeted at those managing common mental health problems. The usefulness of creating ‘to-do’ lists and schedules that remind you to enact certain positive behaviours and give you a sense of reward for carrying out simple, daily tasks came up in both the engagement and co-design sessions. Feeling that you are able to take practical tangible steps to help you through the daily management of an illness is important. With the proliferation of smart phones, a calendar-type app designed specifically for different kinds of mental health management could prove a valuable digital asset. There was also an interest in sharing practical tips and positive coping mechanisms; this could be realised in a variety of online formats, using both existing assets and looking for opportunities to develop new approaches.

Empathy tools There was a desire especially amongst the young people we worked with directly affected by mental health issues, to hear heartfelt, non-glamorised accounts of what it is like to live with mental illness on a practical, day-to-day basis. These could be in a variety of formats; video, audio, comic illustration, written etc. Such accounts were seen as not only important to those suffering from mental ill health as a means to contextualise their own situation, but also as a means to fight stigma. A digital space for sharing these, backed by a wider campaign, would be welcomed. Further exploration of the possibilities of gaming Gaming was discussed quite frequently during our initial engagement sessions, but hardly featured in the later co-design stage. This may have due to the core co-design group being made up of young women (as discussed in the limitations section of the report), whilst the more lively conversations about gaming had come from mixed gender groups in the earlier stages of the project. Whilst being unable to recommend any specific use for gaming in the mental health sphere, we would recommend further research to explore its potential and examining work that is already under way in this field. Many of the young people during our engagement group discussions saw potential in the role play aspect of games as an empathy, learning or enactment tool.

Refer to page 83 for a discussion of the young people’s ideas on empathy tools.

Refer to pages 20, 60 and 101 for further discussion of the potential of gaming.

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7.2 WIDER RECOMMENDATIONS The discussions we had with young people and the ideas they put forward for service improvement were not limited to digital and social media. For the young people, a sea change in perceptions of mental health was seen as pre-requisite for the lasting impact and success of any digital asset created. This has led us to make a series of wider recommendations that would not only compliment and strengthen any innovation in the digital and social media realm, but in fact play a crucial role in the success of a campaign for a more pro-active approach to mental wellbeing.

Online/Offline Duality For young people, the line between online and offline ‘life’ is increasingly blurred. They spend large amounts of time online; some are connected at all times (not always in an active capacity) to social networking sites via their mobile phones. Offline and online social interactions, activities and communication often happen in simultaneity. There needs to be an acknowledgement that online behaviour is quite simply behaviour; online habits, activities and occurrences play as important a role in the mental wellbeing of a young person as offline behaviours and happenings. Online behaviour needs to be discussed and managed when advising, counselling and working with young people; it needs to be seen as an important part of their behaviour in general. Relevant workforces will need to be given the proper training to enable them to do this effectively and with confidence.

Refer to page 50 for discussion of blurring of young people’s online and offline world’s.

Digital Innovation in Public Service Published good practice, and interviews with relevant stakeholders pointed to a need for NHS and public services to take the opportunity to use co-production and digital innovation techniques such as agile development, and lean start-up principles to design, prototype, and learn in delivery. NHS GGC has an opportunity to become an NHS centre for good practice in Scotland for encouraging learning and innovation, building

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7.2 WIDER RECOMMENDATIONS: REVERSE INEQUALITY / EMOTIONAL LITERACY on this work and incorporating learning from programmes such as Innovation Labs. Investment of relatively small sums to develop, prototype and learn from ideas developed through hack weekends and similar intensive development processes could make a significant contribution to emental health in Scotland and beyond.

Reverse Inequality Evidence from both published studies and the co-design sessions show that access to technology is not equally distributed in Scotland and in Glasgow. A cautious approach is often taken by the NHS as regards digital service provision, for fear of excluding those without access to technology. That said, it is clear that it isn’t always the technical barriers that inhibit participation. Most of the young people we spoke to had access to the internet, and functioned as digital citizens, even notwithstanding the various inequalities they experienced. Evidence indicates that young people will prioritise digital connectivity, and therefore services should take account of these choices in accessing those they seek to connect with. Many young people could be described as digitally dominant; they will wish to engage with services primarily through digital means. The digitally dominant should not be excluded by not providing for them.

We recommend realistic equality impact assessment of digital innovations. Whilst it is true that expensive devices like iPhones with unlimited data are hard for most young people to access, most people are able to use technology and email. Any brief for digital development should ensure that developers understand the audience for the asset. An assessment of the type of device used by young people, and the restrictions they face is critical to ensure that the drive to use the newest cutting edge technology does not override the needs of the end-user.

Emotional Literacy The importance of emotional literacy was central to many of our discussions with young people. Increasing the level of emotional literacy amongst young people was seen as a crucial to aid in the prevention and treatment of mental ill-health, and as a means to combat stigma surrounding mental health issues. The young people called for emotional literacy to become a core part of the school curriculum, and to be given as much importance as physical health in this regard (moreover, it shouldn’t been seen as entirely separate from physical health.) In light of a previous point, the discussion of emotionally healthy behaviours would include online actions. The need for specialist teachers in this area was identified. At the very least, we would recommend

Refer to page 74 for the young people’s ideas for the improvement of emotional literacy through teaching in schools.

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7.2 WIDER RECOMMENDATIONS: FIRST RESPONSE IN SCHOOLS regular sessions delivered by visiting experts. In line with previous recommendations, teaching should take a pro-active and positive approach to emotional wellbeing, not simply aiming to raise awareness of issues, but to outline and enact practical steps and techniques that young people can use on a daily basis.

First response in schools Refer to Greig and Jenny’s case studies on pages 17, 25 and 31 for a discussion of the importance of a good first response with in schools.

Many young people had negative experiences as regards the handling of mental health related issues in school, both in terms of wider policy based issues and the actions and comments of individual teachers. Comprehensive training is required for teachers in terms of conduct relating to emotional and mental health related matters, and in order to give them greater confidence, support and resources in providing the first response to a mental health related incident in school. ‘Youth Mental Health First Aid’ and appropriate courses on managing distress should also be a part of normal first aid training for teachers, and taught in schools to pupils, ideally by peers. There was a desire amongst young people to have a designated, specially trained member of staff available in times of distress. In practice this may present many difficulties; young people very often do not want their friends and peers to be aware that they are experiencing emotional and

mental health difficulties, and may fear being seen discussing something with this designated member of staff. However, having more than one member of staff equipped to respond effectively to young people in distress would alleviate this. School nurses could also provide an authority figure in this sense, given the correct training and support. In terms of wider school policies, a positive outlook is required. The pro-active promotion of student (and staff ) mental wellbeing needs to be a top priority. It is crucial that young people experiencing emotional distress or difficulties with mental illness are not treated in a manner that gives the impression of punishment or disruption.

Self-realisation and cultural activities In the findings of this report and previous recommendations, we have acknowledged the importance of the ‘third space’ in regard to a young person’s mental wellbeing. Self-realisation through sport, the arts, and other hobby and extra-curricular activities is crucial. Importantly, these need to take place away from school, allowing the young person to gain friends in entirely different social circles, and form a different set of adult authority figures (ie. not teachers or family). A campaign is required to encourage all young people to have at least one such outlet, with incentives and subsidies provided as required. Cultural organisations and

Refer to page 97 of the literature study for a discussion of the importance of creativity and cultural activities in identity formation in young people.

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7.2 WIDER RECOMMENDATIONS: SELF REALISATION & CULTURAL ACTIVITIES programs should be approached as a means of promoting emotional and mental wellbeing. The more widespread the events, festivals, tv and radio shows, etc that have mental health as a concern, the more effective and wide-reaching the message.

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7.3 RECOMMENDATIONS: USE OF EXISTING SOCIAL MEDIA BY THE NHS Through the findings of this report and previous recommendations, we have demonstrated that a variety of specifically designed, individual digital spaces are needed in order to provide young people with effective mental health support. However, given the power of social networks such as Facebook, YouTube and Twitter in terms of rapid information dissemination to a very wide audience of young people, it is important to make best use of them. The three specific social networks mentioned above - Facebook, YouTube, and to a lesser extent, Twitter - have been highlighted as they have demonstrated sustained use by young people over the last few years. However, the digital landscape changes rapidly; the interactions that the aforementioned networks afford are often modified, and shifting trends see other social networks gaining or losing importance in young people’s internet use

Tribal Use of the Web Young people’s internet use tends to be tribal, both in terms of what social media platforms they use and how and why they use them. These ‘tribal’ use patterns are not dependent on geography or even on a young person’s offline social circles, and will shift within individuals overtime. Therefore, the most sustainable form of recommendations that we can make in this regard centre around interactions that different social media platforms afford, rather than specifically looking at how to use any one network alone. (We would also recommend the appointment of young people as social media managers, as they will be most aware of trending modes of social media use and best aware of how to disseminate information/use the appropriate channels.)

Content Generation and Sharing The sharing of links and pieces of individual content is a core interaction. Content most often shared by young people includes video (including ‘Vines’), music, images (including animated gif’s) and short clips of text in the form of a ‘tweet’ or ‘status update.’ We would recommend the creation of a body of such content, containing useful information, but that is crucially interesting and attractive for young people to consider sharing across a range of social networks. (tips/ info/advice) From the aforementioned, well made

Refer to the young people’s content sharing based concept ‘Button Wall’ on page 76.

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7.3 RECOMMENDATIONS: USE OF EXISTING SOCIAL MEDIA BY THE NHS and attractive videos are particularly useful in terms of their ability to deliver more complex content in an inclusive and engaging way. As well as allowing the dissemination of fragmented pieces of useful content, specific awareness and public information campaigns could make very effective use of these channels.

NHS Brand

Refer to Jenny’s case study insights on page 33.

The NHS is without question a trusted brand with young people for health related information. There is a need for the NHS to understand better ways in which it can maximise this with young people, whilst also being mindful that some ‘tribes’ of young people who may need information may not be so welcoming of ‘official’ channels. It is possible that addressing information in a separate, linked brand may provide an avenue to explore this. WellHappy for instance chose the app route so that it could use a strong brand without and obvious NHS name in the title.

Public Conversations Including Young People It is possible to engage young people in more direct communication through tweets. comment feeds, forums etc. Even if not actively participating, young people can benefit from reading conversations of others (this makes impact of service difficult to measure). Clear parameters of use and expected behaviours need to be set. There is the possibility of interrupting trending negative or potentially damaging conversations amongst young people through hashtags (such as #cutforbieber), commet feeds, forums etc with positive messages/advice/tips. This needs to be done with sensitivity and by an appropriate voice to ensure young people don’t feel intruded on, and subsequently wary of using the platform openly.

Blogging Blog posts provide for more passive use but allow more complex ideas and reflective personal pieces to be expressed. They could be used as empathy tools and give NHS services a more personal, relatable ‘face.’ Programs should be approached as a means of promoting emotional and mental wellbeing. The more widespread the events, festivals, TV and radio shows, etc that have mental health as a concern, the more effective and wide-reaching the message.

Refer to the young people’s ideas on multi-media campaigns on page 73.

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