542031 research-article2014
ANP0010.1177/0004867414542031Australian & New Zealand Journal of PsychiatryKing and Delfabbro
Viewpoint Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(9) 805–808 DOI: 10.1177/0004867414542031
My Facebook family: Should adolescent psychiatric evaluation include information about online social networks?
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Daniel L King and Paul H Delfabbro
Introduction Psychiatry recognises the important role that social relationships play in the wellbeing of adolescents. The strength of social connectedness, the availability of social support, and quality of interactions are all considered critical factors in young people’s susceptibility to mental illness and their capacity to seek assistance. Historically, adolescent social relationships revolved very much around physical spaces: family homes, schools or public spaces such as clubs, parks, shops, or fast food restaurants. However, with the emergence and growing popularity of social media, appraisal of the extent and quality of social relationships now needs to be extended to encompass online activities that may not necessarily involve direct physical contact. One of the most widely used and documented social media sites is Facebook, which reportedly has 1.3 billion monthly active users as of April 2014 (Source: Facebook via Statisticbrain.com). Australian adolescents spend, on average, about 45 minutes on social media in the course of an average day (King et al., 2013). Online social networks have therefore become increasingly accessible and prominent in people’s daily social lives over time. Accordingly, relationships and interactions that take place on the Internet may often come to assume the
importance of those developed in more traditional ways (Davis, 2001; King and Delfabbro, 2014). It is likely that these developments will have a number of important implications for mental health researchers and practitioners. To date, much of the discussion concerning the growth in social media has related to the potentially negative impacts of excessive engagement with this technology: (a) the impact of online context on symptoms of mental health disorders, such as anxiety (Shepherd and Edelmann, 2005); (b) the emergence of behavioural syndromes that primarily involve online activities, such as online gambling (King et al., 2010) and Internet gaming (Ferguson et al., 2011); (c) the benefit and challenges of online methods of assessment and intervention (Tate et al., 2009), and (d) ethical dilemmas associated with the blurring of boundaries between social and professional spheres in the client– psychiatrist relationship (Appelbaum and Kopelman, 2014). However, other potentially important elements have received less attention. In our view, one of these oversights is the potential role that social media could play as a method for gaining insight into the mental state and social functioning of individuals. Given that many of these sites encourage people to share private information – their interests, opinions and wellbeing – with friends or external observers,
often on a daily basis, such information may be useful in gaining a more complete understanding of the client, including presenting problems and family history. By this, we refer to information provided by clients themselves about their social networking, rather than information sought out independently by a clinician with or without the client’s consent (see Appelbaum and Kopelman, 2014). Online social networks may be a source of useful observations about the familial system and other interpersonal relationships, including the quality and closeness, stability, safety, and emotional investment within these relationships. This information could be used to consolidate other sources of information about the organisation and integrity of family relationships (e.g. family enmeshment, relationship fractures and boundaries, and so on), and therefore have implications for a range of therapeutic intervention strategies. For many adolescent clients, the inclusion of questions about online social networks within the standard interview schedule may also
School of Psychology, The University of Adelaide, Adelaide, Australia Corresponding author: Daniel L. King, School of Psychology, The University of Adelaide, Hughes Building, Adelaide SA 5005, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(9)
Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
806 be helpful in alliance-building. In addition, some adolescents may initially feel more comfortable describing their familial relationships from the point of view of their online social network profile or by using terms of reference (e.g. “blocking”, “sharing”, and “liking”) unique to online social networks (Subrahmanyam and Greenfield, 2008).
Online social networks as social context Online communication represents a fundamentally different style of social interaction as compared with face-toface communication (Suler, 2001). Online social networks have distinct appeal due to their constant accessibility, minimal effort required to participate, and high “refresh rate” or constant stream of new information from or about other users. Known aspects of online communication include: (1) minimal or a total lack of non-verbal behaviour; (2) low perceived accountability for unintended or deliberate transgression; (3) invisibility and/or anonymity of users; (4) non-synchronicity; and (5) features designed to create depersonalisation (e.g. non-human avatars, usernames, and tags or handles). For these reasons, individuals who are socially anxious, lack real-world social skills, or over-engage in self-monitoring often indicate a preference for social interaction within online environments (Davis, 2001). This may be partly due to the fact that the Internet provides a psychosocial moratorium that insulates against the real or perceived risks of self-presentation and self-disclosure. In this sense, the online medium offers a less confronting or effortful means of seeking out emotionally intense (albeit titrated) social encounters. Clinicians should be mindful that online communication styles and relationships may often be a distortion or hyper-realised representation of a person’s real-life social skills and social context. An adolescent with
ANZJP Perspectives depression, for example, may have forged a unique online identity on Facebook (or on other sites) with many hundreds of “friends” but may have no intimate or meaningful social connection outside of this online network. As another example, an adolescent with social anxiety may report having greater confidence and emotional expression when interacting with others online as compared with in real life. The transience and superficiality of online relationships in such cases may become evident upon further questioning, although this may be beyond the scope of an initial consultation. Nevertheless, an impression of how online social network use may maintain and intensify depressive symptomatology (e.g. inactivity, disturbed sleep, belief that one is worthless in the real world, etc.) and limit access to real-life social support and activities could be useful for formulation and intervention. Despite the fact that online social networks are distinct in many ways from real-life social contexts, social network sites have many social functions that may provide insight into the client’s interpersonal functioning. Common features of websites such as Facebook include a personal profile featuring photos and images, lists of personal interests, memorable life events, and other personal information. Users can communicate with “friends” (those users who are permitted to view information on their profile) and other users through private or public messages, and share content that include website URLs, images, and video content. In this sense, these websites provide a semipermanent record of information about the client’s history of interpersonal relationships and experience which may become useful reference points when examining mental health concerns. Adolescent clients’ online social experiences can sometimes feature prominently within a personal narrative of the precipitating and perpetuating factors of a presenting problem.
For example, a client may refer to an inability to cope with a series of distressing online social experiences (e.g. online arguments, cyberbullying, exploitation of personal information, or interpersonal relationship breakdown) as a reason to seeking treatment. Alternatively, a client may highlight an experience of “losing” (e.g. being banned from, or having deleted) an online account as a significant personal loss or life event. Such experiences should not be overlooked given their relevance to the client’s difficulties in managing broad issues that include mismanagement of relationship boundaries, social anxiety, emotion regulation issues, poor self-concept, or lack of self-actualisation.
Family history assessment Information about online social networks can often be helpful when gathering information about the client’s family organisation as well as the strength of relationships among family members, as part of a standard assessment of family history (see Cepeda, 2010). Construction of a formal pedigree or genogram is typically used to delineate family relationships and identify any family history of mental illness (Goldberg and Murray, 2006). Especially in regard to adolescents with complex or blended families or adolescents living across multiple households, it may be helpful for online family relationships to be incorporated into a standard genogram. The nature of the online relationship may be explored to obtain a secondary measure of frequency of social contact, closeness, and social support. An advantage of gathering this information is it may identify significant relationships that are limited in terms of real-life contact but involve frequent online connection (e.g. an estranged biological parent or long-distance intimate relationship). Such information may not always emerge naturally, particularly if an adolescent client employs ambiguous language that implies noncontact, such as “I’ve never met him” or “I don’t see them anymore”.
Australian & New Zealand Journal of Psychiatry, 48(9) Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
807
King and Delfabbro Clients’ social media presence and use may be seemingly complex but should not necessarily be considered too onerous to assess. In practice, a clinician may begin by mapping out the clients’ online social context by asking whether the client has an online social network account (e.g. Facebook profile) and determining who in the immediate family has a profile on that site. Adding this information to the client’s genogram may provide a helpful summary. A special symbol to denote ownership of a social media profile, e.g. an ‘F’ to indicate a Facebook account, with modifications to denote that the person does not have an account, or has been blocked or deleted by another family member, or vice versa. Example practical questions include: Who in your family are you “friends” with on Facebook (or another relevant site)? Is there anyone in your family with whom you are not Facebook friends? Was it your choice not to be friends? Has anyone in your family blocked you on Facebook? Have you blocked anyone in your family on Facebook? Do your parents check your Facebook page? Do your parents have any rules about Facebook use?
Parenting style and attachment issues A guiding principle for family assessment and therapy is that adolescents’ psychological problems cannot be properly understood devoid of their relational context (Angold and Costello, 2000; Carr, 2006 Cepeda, 2010). Although we have noted so far that online social networks cannot be considered as a perfect analogue of real-life relationships, social media activities nevertheless do provide some initial insights into the parent– child relationship. For example, a parent who is unaware of (or aware but non-responsive to) an adolescent involved in potentially unsafe online activities on Facebook (e.g. romantic relationship with an older person) may not be attuned to basic safety and
security needs. Similarly, a parent who has blocked his or her own child on Facebook may indicate that the parent is often rejecting of their child and/or has difficulty in establishing appropriate boundaries. On the other hand, an adolescent who has blocked a parent on Facebook may indicate that the adolescent perceives the parent as being emotionally unavailable or difficult to trust. Some parent–child conflicts may occur almost exclusively online, where both parties are less likely to feel inhibited and more likely to disclose their true feelings toward each other, in contrast to real life where true feelings are hidden or repressed due to mutual avoidance of unwanted affective responses. Social media use may also provide insight into parenting styles. A parent that monitors all aspects of the adolescents’ Facebook use may indicate an overbearing or authoritarian parenting style. A parent that totally forbids Facebook may indicate overprotection or interference with the adolescent’s attempts toward identity formation outside of the nuclear family (Allison et al., 2006). Family enmeshment processes may also be observed on social media. In enmeshed families, members of the adolescent’s extended family may use manipulation, demands, or threats on Facebook (with varying levels of transparency depending on privacy settings) via instant messages or comments on a user’s status. Family members with diagnosed borderline personality disorder are likely to create significant difficulties for the adolescent to maintain appropriate decorum and boundaries on Facebook. Similarly, adolescents with emerging borderline personality traits may disclose, or share directly on their smartphone in session, intense social experiences on social media in which they behaved reactively and impulsively.
Risk and safety issues Social media information may be relevant to the standard assessment of risk and safety issues. A clinician
should attend to whether the client has a public (i.e. freely visible) profile with limited security or permissions in order to consider any potential risks that this may expose to the young person (e.g. unwelcome contact by older persons, or exposure to unsolicited information posted onto their profile). This may be particularly relevant for vulnerable clients with a known history of abuse or solicitation. Clinicians and parents (as well as other persons of relevance to the adolescent’s care and upbringing) should be aware that the privacy settings on the client’s profile may also potentially compromise the privacy of information about others in the family network. The presence of online bullying also warrants evaluation when identifying stressors. Adolescents with current or past experiences of bullying may often be the target of cyberbullying on their social networking profile. Finally, another potential mental health risk issue is adolescents’ membership to online social groups that may reinforce the negative affective and cognitive dimensions of mental health disorders. For example, in relation to eating disorders, there are known to be pro-anorexia (or “proana”) discussion groups on social media sites (e.g. Tumblr) that actively encourage those with eating disorders to maintain low weight and resist therapeutic measures aimed at recovery (Bardone-Cone and Cass, 2006).
Conclusions Online social networks play a major role in adolescents’ social lives and self-presentation. Therefore, understanding how these clients use social media may provide information of considerable clinical value. It has been argued previously that the practice of psychiatry faces significant challenges in understanding and responding to how social media alters basic notions of privacy, connectivity, and communication (Appelbaum and Kopelman, 2014). We are in agreement with this general proposition and suggest that
Australian & New Zealand Journal of Psychiatry, 48(9)
Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
808 there is great potential for information about clients’ social media use to be leveraged for the purpose of standard psychiatric evaluation. Clinicians with basic knowledge of the terminology and dynamics of online social networks may also find it easier to engage with some adolescent clients. As social media continues to assume a significant role in adolescent development, there remains a need for further research on its potential impacts. A focus on clinical issues related to social media in adolescence may be helpful in informing the practice of psychiatry in this growing area. Keywords Social media, internet, adolescent, family history, genogram
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
ANZJP Perspectives Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Allison SE, von Wahlde L, Shockley T, et al. (2006) The development of the self in the era of the Internet and role-playing fantasy games. American Journal of Psychiatry 163: 381–385. Angold A and Costello EJ (2000) The Child and Adolescent Assessment (CAPA). Journal of the American Academy of Child and Adolescent Psychiatry 39: 39–48. Appelbaum PS and Kopelman A (2014) Social media’s challenges for psychiatry. World Psychiatry 13: 21–23. Bardone-Cone AM and Cass KM (2006) Investigating the impact of pro-anorexia sites: A pilot study. European Eating Disorders Review 14: 256–262. Carr A (2006) The handbook of child and adolescent clinical psychology: A contextual approach. London, UK: Routledge. Cepeda C (2010) Clinical manual for the psychiatric interview of children and adolescents. Arlington, VA: American Psychiatric Publishing. Davis RA (2001) A cognitive-behavioral model of pathological Internet use. Computers in Human Behavior 17: 187–195. Facebook statistics. Retrieved from: http://www. statisticbrain.com/facebook-statistics/
Ferguson CJ, Coulson M and Barnett J (2011) A meta-analysis of pathological gaming prevalence and comorbidity with mental health, academic and social problems. Journal of Psychiatric Research 45: 1573–1578. King DL and Delfabbro PH (2014) The cognitive psychology of Internet gaming disorder. Clinical Psychology Review 34: 298–308. King DL, Delfabbro PH and Griffiths MD (2010) The convergence of gambling and digital media: Implications for gambling in young people. Journal of Gambling Studies 26: 175–187. King DL, Delfabbro PH, Zwaans T, et al. (2013) Clinical features and axis I comorbidity of Australian adolescent pathological Internet and video-game users. Australian and New Zealand Journal of Psychiatry 47: 1058–1067. Goldberg D and Murray R (2006) The Maudsley Handbook of Practical Psychiatry (5th Edition). Oxford, UK: Oxford University Press. Shepherd R and Edelmann RJ (2005) Reasons for internet use and social anxiety. Personality and Individual Differences 39: 949–958. Subrahmanyam K and Greenfield P (2008) Online communication and adolescent relationships. The Future of Children 18: 119–146. Suler J (2001) The online disinhibition effect. CyberPsychology & Behavior 7: 321–326. Tate DF, Finkelstein EA, Khavjou O, et al. (2009) Cost effectiveness of internet interventions: Review and recommendations. Annals of Behavioral Medicine 38: 40–45.
Australian & New Zealand Journal of Psychiatry, 48(9) Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
ANP0010.1177/0004867414542031Australian & New Zealand Journal of PsychiatryKing and Delfabbro
Viewpoint Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(9) 805–808 DOI: 10.1177/0004867414542031
My Facebook family: Should adolescent psychiatric evaluation include information about online social networks?
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Daniel L King and Paul H Delfabbro
Introduction Psychiatry recognises the important role that social relationships play in the wellbeing of adolescents. The strength of social connectedness, the availability of social support, and quality of interactions are all considered critical factors in young people’s susceptibility to mental illness and their capacity to seek assistance. Historically, adolescent social relationships revolved very much around physical spaces: family homes, schools or public spaces such as clubs, parks, shops, or fast food restaurants. However, with the emergence and growing popularity of social media, appraisal of the extent and quality of social relationships now needs to be extended to encompass online activities that may not necessarily involve direct physical contact. One of the most widely used and documented social media sites is Facebook, which reportedly has 1.3 billion monthly active users as of April 2014 (Source: Facebook via Statisticbrain.com). Australian adolescents spend, on average, about 45 minutes on social media in the course of an average day (King et al., 2013). Online social networks have therefore become increasingly accessible and prominent in people’s daily social lives over time. Accordingly, relationships and interactions that take place on the Internet may often come to assume the
importance of those developed in more traditional ways (Davis, 2001; King and Delfabbro, 2014). It is likely that these developments will have a number of important implications for mental health researchers and practitioners. To date, much of the discussion concerning the growth in social media has related to the potentially negative impacts of excessive engagement with this technology: (a) the impact of online context on symptoms of mental health disorders, such as anxiety (Shepherd and Edelmann, 2005); (b) the emergence of behavioural syndromes that primarily involve online activities, such as online gambling (King et al., 2010) and Internet gaming (Ferguson et al., 2011); (c) the benefit and challenges of online methods of assessment and intervention (Tate et al., 2009), and (d) ethical dilemmas associated with the blurring of boundaries between social and professional spheres in the client– psychiatrist relationship (Appelbaum and Kopelman, 2014). However, other potentially important elements have received less attention. In our view, one of these oversights is the potential role that social media could play as a method for gaining insight into the mental state and social functioning of individuals. Given that many of these sites encourage people to share private information – their interests, opinions and wellbeing – with friends or external observers,
often on a daily basis, such information may be useful in gaining a more complete understanding of the client, including presenting problems and family history. By this, we refer to information provided by clients themselves about their social networking, rather than information sought out independently by a clinician with or without the client’s consent (see Appelbaum and Kopelman, 2014). Online social networks may be a source of useful observations about the familial system and other interpersonal relationships, including the quality and closeness, stability, safety, and emotional investment within these relationships. This information could be used to consolidate other sources of information about the organisation and integrity of family relationships (e.g. family enmeshment, relationship fractures and boundaries, and so on), and therefore have implications for a range of therapeutic intervention strategies. For many adolescent clients, the inclusion of questions about online social networks within the standard interview schedule may also
School of Psychology, The University of Adelaide, Adelaide, Australia Corresponding author: Daniel L. King, School of Psychology, The University of Adelaide, Hughes Building, Adelaide SA 5005, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(9)
Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
806 be helpful in alliance-building. In addition, some adolescents may initially feel more comfortable describing their familial relationships from the point of view of their online social network profile or by using terms of reference (e.g. “blocking”, “sharing”, and “liking”) unique to online social networks (Subrahmanyam and Greenfield, 2008).
Online social networks as social context Online communication represents a fundamentally different style of social interaction as compared with face-toface communication (Suler, 2001). Online social networks have distinct appeal due to their constant accessibility, minimal effort required to participate, and high “refresh rate” or constant stream of new information from or about other users. Known aspects of online communication include: (1) minimal or a total lack of non-verbal behaviour; (2) low perceived accountability for unintended or deliberate transgression; (3) invisibility and/or anonymity of users; (4) non-synchronicity; and (5) features designed to create depersonalisation (e.g. non-human avatars, usernames, and tags or handles). For these reasons, individuals who are socially anxious, lack real-world social skills, or over-engage in self-monitoring often indicate a preference for social interaction within online environments (Davis, 2001). This may be partly due to the fact that the Internet provides a psychosocial moratorium that insulates against the real or perceived risks of self-presentation and self-disclosure. In this sense, the online medium offers a less confronting or effortful means of seeking out emotionally intense (albeit titrated) social encounters. Clinicians should be mindful that online communication styles and relationships may often be a distortion or hyper-realised representation of a person’s real-life social skills and social context. An adolescent with
ANZJP Perspectives depression, for example, may have forged a unique online identity on Facebook (or on other sites) with many hundreds of “friends” but may have no intimate or meaningful social connection outside of this online network. As another example, an adolescent with social anxiety may report having greater confidence and emotional expression when interacting with others online as compared with in real life. The transience and superficiality of online relationships in such cases may become evident upon further questioning, although this may be beyond the scope of an initial consultation. Nevertheless, an impression of how online social network use may maintain and intensify depressive symptomatology (e.g. inactivity, disturbed sleep, belief that one is worthless in the real world, etc.) and limit access to real-life social support and activities could be useful for formulation and intervention. Despite the fact that online social networks are distinct in many ways from real-life social contexts, social network sites have many social functions that may provide insight into the client’s interpersonal functioning. Common features of websites such as Facebook include a personal profile featuring photos and images, lists of personal interests, memorable life events, and other personal information. Users can communicate with “friends” (those users who are permitted to view information on their profile) and other users through private or public messages, and share content that include website URLs, images, and video content. In this sense, these websites provide a semipermanent record of information about the client’s history of interpersonal relationships and experience which may become useful reference points when examining mental health concerns. Adolescent clients’ online social experiences can sometimes feature prominently within a personal narrative of the precipitating and perpetuating factors of a presenting problem.
For example, a client may refer to an inability to cope with a series of distressing online social experiences (e.g. online arguments, cyberbullying, exploitation of personal information, or interpersonal relationship breakdown) as a reason to seeking treatment. Alternatively, a client may highlight an experience of “losing” (e.g. being banned from, or having deleted) an online account as a significant personal loss or life event. Such experiences should not be overlooked given their relevance to the client’s difficulties in managing broad issues that include mismanagement of relationship boundaries, social anxiety, emotion regulation issues, poor self-concept, or lack of self-actualisation.
Family history assessment Information about online social networks can often be helpful when gathering information about the client’s family organisation as well as the strength of relationships among family members, as part of a standard assessment of family history (see Cepeda, 2010). Construction of a formal pedigree or genogram is typically used to delineate family relationships and identify any family history of mental illness (Goldberg and Murray, 2006). Especially in regard to adolescents with complex or blended families or adolescents living across multiple households, it may be helpful for online family relationships to be incorporated into a standard genogram. The nature of the online relationship may be explored to obtain a secondary measure of frequency of social contact, closeness, and social support. An advantage of gathering this information is it may identify significant relationships that are limited in terms of real-life contact but involve frequent online connection (e.g. an estranged biological parent or long-distance intimate relationship). Such information may not always emerge naturally, particularly if an adolescent client employs ambiguous language that implies noncontact, such as “I’ve never met him” or “I don’t see them anymore”.
Australian & New Zealand Journal of Psychiatry, 48(9) Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
807
King and Delfabbro Clients’ social media presence and use may be seemingly complex but should not necessarily be considered too onerous to assess. In practice, a clinician may begin by mapping out the clients’ online social context by asking whether the client has an online social network account (e.g. Facebook profile) and determining who in the immediate family has a profile on that site. Adding this information to the client’s genogram may provide a helpful summary. A special symbol to denote ownership of a social media profile, e.g. an ‘F’ to indicate a Facebook account, with modifications to denote that the person does not have an account, or has been blocked or deleted by another family member, or vice versa. Example practical questions include: Who in your family are you “friends” with on Facebook (or another relevant site)? Is there anyone in your family with whom you are not Facebook friends? Was it your choice not to be friends? Has anyone in your family blocked you on Facebook? Have you blocked anyone in your family on Facebook? Do your parents check your Facebook page? Do your parents have any rules about Facebook use?
Parenting style and attachment issues A guiding principle for family assessment and therapy is that adolescents’ psychological problems cannot be properly understood devoid of their relational context (Angold and Costello, 2000; Carr, 2006 Cepeda, 2010). Although we have noted so far that online social networks cannot be considered as a perfect analogue of real-life relationships, social media activities nevertheless do provide some initial insights into the parent– child relationship. For example, a parent who is unaware of (or aware but non-responsive to) an adolescent involved in potentially unsafe online activities on Facebook (e.g. romantic relationship with an older person) may not be attuned to basic safety and
security needs. Similarly, a parent who has blocked his or her own child on Facebook may indicate that the parent is often rejecting of their child and/or has difficulty in establishing appropriate boundaries. On the other hand, an adolescent who has blocked a parent on Facebook may indicate that the adolescent perceives the parent as being emotionally unavailable or difficult to trust. Some parent–child conflicts may occur almost exclusively online, where both parties are less likely to feel inhibited and more likely to disclose their true feelings toward each other, in contrast to real life where true feelings are hidden or repressed due to mutual avoidance of unwanted affective responses. Social media use may also provide insight into parenting styles. A parent that monitors all aspects of the adolescents’ Facebook use may indicate an overbearing or authoritarian parenting style. A parent that totally forbids Facebook may indicate overprotection or interference with the adolescent’s attempts toward identity formation outside of the nuclear family (Allison et al., 2006). Family enmeshment processes may also be observed on social media. In enmeshed families, members of the adolescent’s extended family may use manipulation, demands, or threats on Facebook (with varying levels of transparency depending on privacy settings) via instant messages or comments on a user’s status. Family members with diagnosed borderline personality disorder are likely to create significant difficulties for the adolescent to maintain appropriate decorum and boundaries on Facebook. Similarly, adolescents with emerging borderline personality traits may disclose, or share directly on their smartphone in session, intense social experiences on social media in which they behaved reactively and impulsively.
Risk and safety issues Social media information may be relevant to the standard assessment of risk and safety issues. A clinician
should attend to whether the client has a public (i.e. freely visible) profile with limited security or permissions in order to consider any potential risks that this may expose to the young person (e.g. unwelcome contact by older persons, or exposure to unsolicited information posted onto their profile). This may be particularly relevant for vulnerable clients with a known history of abuse or solicitation. Clinicians and parents (as well as other persons of relevance to the adolescent’s care and upbringing) should be aware that the privacy settings on the client’s profile may also potentially compromise the privacy of information about others in the family network. The presence of online bullying also warrants evaluation when identifying stressors. Adolescents with current or past experiences of bullying may often be the target of cyberbullying on their social networking profile. Finally, another potential mental health risk issue is adolescents’ membership to online social groups that may reinforce the negative affective and cognitive dimensions of mental health disorders. For example, in relation to eating disorders, there are known to be pro-anorexia (or “proana”) discussion groups on social media sites (e.g. Tumblr) that actively encourage those with eating disorders to maintain low weight and resist therapeutic measures aimed at recovery (Bardone-Cone and Cass, 2006).
Conclusions Online social networks play a major role in adolescents’ social lives and self-presentation. Therefore, understanding how these clients use social media may provide information of considerable clinical value. It has been argued previously that the practice of psychiatry faces significant challenges in understanding and responding to how social media alters basic notions of privacy, connectivity, and communication (Appelbaum and Kopelman, 2014). We are in agreement with this general proposition and suggest that
Australian & New Zealand Journal of Psychiatry, 48(9)
Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
808 there is great potential for information about clients’ social media use to be leveraged for the purpose of standard psychiatric evaluation. Clinicians with basic knowledge of the terminology and dynamics of online social networks may also find it easier to engage with some adolescent clients. As social media continues to assume a significant role in adolescent development, there remains a need for further research on its potential impacts. A focus on clinical issues related to social media in adolescence may be helpful in informing the practice of psychiatry in this growing area. Keywords Social media, internet, adolescent, family history, genogram
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
ANZJP Perspectives Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Allison SE, von Wahlde L, Shockley T, et al. (2006) The development of the self in the era of the Internet and role-playing fantasy games. American Journal of Psychiatry 163: 381–385. Angold A and Costello EJ (2000) The Child and Adolescent Assessment (CAPA). Journal of the American Academy of Child and Adolescent Psychiatry 39: 39–48. Appelbaum PS and Kopelman A (2014) Social media’s challenges for psychiatry. World Psychiatry 13: 21–23. Bardone-Cone AM and Cass KM (2006) Investigating the impact of pro-anorexia sites: A pilot study. European Eating Disorders Review 14: 256–262. Carr A (2006) The handbook of child and adolescent clinical psychology: A contextual approach. London, UK: Routledge. Cepeda C (2010) Clinical manual for the psychiatric interview of children and adolescents. Arlington, VA: American Psychiatric Publishing. Davis RA (2001) A cognitive-behavioral model of pathological Internet use. Computers in Human Behavior 17: 187–195. Facebook statistics. Retrieved from: http://www. statisticbrain.com/facebook-statistics/
Ferguson CJ, Coulson M and Barnett J (2011) A meta-analysis of pathological gaming prevalence and comorbidity with mental health, academic and social problems. Journal of Psychiatric Research 45: 1573–1578. King DL and Delfabbro PH (2014) The cognitive psychology of Internet gaming disorder. Clinical Psychology Review 34: 298–308. King DL, Delfabbro PH and Griffiths MD (2010) The convergence of gambling and digital media: Implications for gambling in young people. Journal of Gambling Studies 26: 175–187. King DL, Delfabbro PH, Zwaans T, et al. (2013) Clinical features and axis I comorbidity of Australian adolescent pathological Internet and video-game users. Australian and New Zealand Journal of Psychiatry 47: 1058–1067. Goldberg D and Murray R (2006) The Maudsley Handbook of Practical Psychiatry (5th Edition). Oxford, UK: Oxford University Press. Shepherd R and Edelmann RJ (2005) Reasons for internet use and social anxiety. Personality and Individual Differences 39: 949–958. Subrahmanyam K and Greenfield P (2008) Online communication and adolescent relationships. The Future of Children 18: 119–146. Suler J (2001) The online disinhibition effect. CyberPsychology & Behavior 7: 321–326. Tate DF, Finkelstein EA, Khavjou O, et al. (2009) Cost effectiveness of internet interventions: Review and recommendations. Annals of Behavioral Medicine 38: 40–45.
Australian & New Zealand Journal of Psychiatry, 48(9) Downloaded from anp.sagepub.com at GEORGIAN COURT UNIV on April 21, 2015
