Social media and adolescent mental health: the good, the bad and the ugly

Abstract

Background: Social media are integral in the lives of adolescents. Practitioners need to be able to assess risk, and social media are potentially a new dimension to consider. Adolescent voices and practitioner perspectives are central to understanding the relationship between social media and mental health, yet there is limited work that highlights their views.

Aims: This paper aims to illuminate the perspectives of adolescents and practitioners about social media and mental health.

Method: Eight focus groups, six with adolescents aged 11–18 years and two with mental health practitioners, were conducted. Ethical approval was provided. Discussions allowed for expression of experiences, views and opinions of the relationship between social media and mental health.

Results: Participants discussed what might be thought of as the “good”, the “bad” and the “ugly” side of social media, navigating the benefits of social media to well-being against possible negative impacts on adolescents. They differentiated personal use from third party attributions whereby they extolled the risk to adolescents outside of their personal group. Much of the negative rhetoric of social media was repeated by mental health practitioners, although there was some acknowledgement of potential benefit.

Conclusions: Practitioners need to consider social media and its role in practice. When risk-assessing adolescents, it is arguably useful to include a social media dimension, without presuming the relationship will be negative.

Keywords:

• Adolescents
• mental health
• qualitative
• social media

Introduction

For adolescents, social media and Internet use are almost ubiquitous. In the UK, 83% have a smartphone and 99% go online for at least 21-hours-per-week (Ofcom, 2017). Similar figures are reported in the US (Anderson & Jiang, 2018) and across Europe (Livingstone, Haddon, Vincent, Mascheroni, & Òlafsson, 2014). Of concern for society is the possible negative impact of social media on adolescent mental health (Richards, Caldwell, & Go, 2015), as there is some evidence linking use with low self-esteem, anxiety and depression (Woods & Scott, 2016) amongst other detriments. The evidence base in the field is mixed, leading to tensions about possible benefits to mental health, including relieving stress and protecting well-being (Allen, Ryan, Gray, McInerney, & Waters, 2014) and risks that social media may cause or exacerbate mental health conditions, which is a concern for parents (George & Odgers, 2015). For some, there is a drive to protect adolescents online arguing that they are vulnerable to harm, and for others, there is a necessity to empower them as they often have digital skills underestimated by adults (Livingstone, Bober, & Helsper, 2005).

Empowering adolescents is a central endeavour for mental health services. Mental health practitioners work in adolescent-centred ways, respecting their rights to be involved in decision-making. This is consistent with the United Nations (1989) Convention on the Rights of the Child. In this way, the task of mental health practitioners in considering the role of social media when engaged in initial assessments, diagnosis and treatment of conditions is important. The way they do this will depend on their personal views of social media and their knowledge of the benefits and risk in the general adolescent population. Practitioners need to be well-informed of the potential benefits and risks, so they can effectively engage, educate and treat adolescents and their families (Reid & Weigle, 2014). Nonetheless, survey research has shown that professionals, like psychiatrists, have concerns about adolescent smartphone usage, feeling that time spent online should be restricted and that smartphone ownership should have an age limit (Lee et al., 2015), which is not necessarily congruent with the views of adolescents (O'Reilly, Dogra, Whiteman et al., 2018). Furthermore, many adolescents benefit from the smartphone and evidence suggest it is only a minority who are at risk (Odgers, 2018).

Rhetorically, the negative impacts of social media are arguably overstated, and benefits to mental health potentially underestimated (Betton & Woollard, 2019). Tensions in the evidence base can be problematic for practitioners when trying to work with families, and I argue that an understanding of adolescent perspectives and experiences could potentially inform their understanding. Largely the evidence base examining adolescents’ screen use has been quantitative, with large-scale surveys across Europe and wider (e.g. Livingstone et al., 2005). While such surveys are beneficial for an understanding of screen times, qualitative evidence is just emerging. Social science work in mental health focusing on language and experience has placed adolescents at the centre of research to better understand the relationship between social media and mental health (e.g., Ahn, 2012; Barry, Sidoti, Briggs, Reiter, & Lindsey, 2017). Mental health practice as a field values the role of language and perspective, and much of the institutional task depends on adolescents’ descriptions and experiences, and therefore, qualitative research is crucial.

Aims

I argue that by focusing on the perspectives of adolescents and mental health practitioners, we can begin to make sense of some of the statistics and broader issues at stake to better appreciate the relationship between social media and mental health from the point of view of those most affected. In other words, those young people whose mental well-being has been rhetorically positioned as “at risk” and those professionals charged with managing and treating any subsequent mental health impact, i.e. those stakeholders who are at the forefront of the social media and mental health debate. The project asked “what do adolescents and mental health practitioners think of social media in relation to mental health?”

Methods

Data collection

To better appreciate the relationship between social media and mental health, the perspectives of those directly involved are beneficial. To assure demographic diversity, we recruited adolescents through secondary schools in London and Leicester, two large UK cities. We conducted six focus groups with non-clinical samples of adolescents (three Leicester and three London) aged 11–18 years old (N = 54, 6–9 per group) (mean age 13.96 years; SD; 2.07) and two groups with mental health practitioners from one Child and Adolescent Mental Health Service (CAMHS) (N=8); See Tables 1 and 2. Focus groups were utilised to gain the perspectives of participants rather than interviews as they promote the space for sharing ideas and engaging with contributions made by different parties (Willig, 2008). Sampling adequacy was consistent with qualitative quality indicators of saturation achieved within and across groups (Hancock, Amankwaa, Revell, & Mueller, 2016). The schedule of questions was organised round three core categories that reflected the focus of the broader project and included adolescents’ own conceptualisations of mental health and mental health conditions, opinions and experiences of social media, and potential of using social media for mental health promotion.

Table 1. Demographics of the adolescents by gender.

	Male	Female	Total
London	18	9	27
Leicester	12	15	27
Total	30	24	54

Table 2. Demographics of the adolescents by ethnicity.

	White British	South Asian	African	Middle East	Eastern European	Other	Total
London	0	11	4	5	4	3	27
Leicester	15	7	0	4	1	0	27
Total	15	18	4	9	5	3	54

Analysis

A thematic design was utilised to better appreciate the salient issues pertinent to participants and their views of the relationship between social media and mental health. Thematic analysis promotes a data-driven strategy allowing for a meaning-making focus (Braun & Clarke, 2006). A robust and systematic coding process across four coders was mapped across the data corpus. Initially, this was conducted independently to create four coding tables. Through face-to-face meetings, the four coding tables were collapsed into one, where all key issues were integrated together, and all code labels were agreed. There was little disagreement across coders, although some fragmented codes into more sub-codes than others which were merged in the final version. Disagreement was overcome through a consultation process and checking against the methodological literature to ensure procedure was followed. The final table of codes was organised into 122 conceptual categories, and a broad synthesis of the three overarching themes relevant to the research question is presented here in this paper.

Ethics

Our study was governed by the University of Leicester who provided ethics approval. Written consent was obtained from parents for those 15 years and younger, and all adolescents and mental health practitioners provided written consent following the provision of age-appropriate information.

Results

The relationship between social media and mental health is complex and multidimensional. The possible benefits and risks facing adolescents have created tension and controversy, not least amongst practitioners who are tasked with understanding any possible relationship between social media use and the young person presenting problems. In this research, the broader tensions were reified through discussions as the nebulous relationship was considered. Three themes were identified in terms of how participants rhetorically constructed the relationship between social media and mental health: 1) the good (those perceived positive impacts on well-being); 2) the bad (possible risks faced and overuse of social media); and 3) the ugly (the perceived more severe negative impacts on mental health); each are considered in turn.

Theme one: the good

A negative rhetoric is imbued across government concerns (see for example, HM Government, 2019) and mental health practices (see Sussman & DeJong, 2018), and arguably are frequently appearing in media reports. It is, however, important not to overlook the possible benefits to adolescent well-being and opportunities for mental health promotion that social media may have (O'Reilly, Dogra, Hughes et al., 2018). In discussions, the adolescents reported a range of ways they used social media to protect their mental health. This narrative was also considered by practitioners who felt that the positive side to social media could be strengthened and promoted.

It is well-established in developmental psychology that strong peer relationships, social skills and support networks are important for preventing the onset of mental health conditions and for supporting overall psychological well-being (Keenan, Evans, & Crowley, 2016). This human need for connectivity was oriented to across groups as both adolescents and practitioners reported on the potential benefits of social media to reduce isolation, improve social skills and provide a platform for continued communication.

It [social media] makes you more social

P8-Leicester-17-18-years

It’s a way of communicating with people, maybe like really good friends you wouldn’t see very often

P4-Leicester-15-16-years

It could be a way to connect with your old friends, people you lost touch with

P6-London-12-13-years

Friendship was characterised as a central aspect of adolescent life throughout the discussion, and here, we can see social media as providing a mechanism to maintain friendships when physical distance was a potential obstacle. The social aspect of social media was emphasised as some attributed its use with improving their social skill set.

It was recognised by participants that skills in communication and social interaction are variable in adolescence. For example, for those diagnosed with mental health conditions it was argued that this group is vulnerable to isolation, particularly looked-after children (e.g., children in care, foster care etc.) who are more transient. Mental health practitioners recognised that the communication and connectivity of social media could be especially beneficial for this group, giving them more positive outcomes consistent with their peers.

It gives them contact with people when they’re so isolated or people are transient in their lives

P2-CAMHS-group1

While communication and social interaction were viewed as essential to adolescent well-being, it was also acknowledged that contemporary adolescents are subjected to significant levels of stress and pressure, which can be a threat to positive health. Promoting well-being and protecting adolescent mental health was felt to require some active participation in activities that reduce stress and help the young person manage the more challenging aspects of their lives. This was a strong issue for the participants as they reported different ways in which being connected to a device enabled a resilience to stress and prevented mental ill health.

When I am on social media I am away from revising, it is all positive

P5-Leicester-17-18-years

I usually like to go on YouTube, it relaxes me

P5-London-13-14-years

It can be a distraction from the things around you and makes you less stressed

P1-London-12-13-years

Consistent across the adolescent focus groups was discussions of the risk factors to threaten mental health. They reported a wide range of external stressors that they found challenging to cope with, including exam pressure, school work, deadlines, parental interference, maintaining friendships and so forth. Notably, therefore, using social media was an active strategy to reduce stress and as a distraction from those aspects of life they constructed as negative.

Theme two: the bad

The rhetoric related to adolescent mental health and social media has examined “the bad”, linking over use or inappropriate use with low self-esteem, disturbed sleep patterns, fear-of-missing-out (Betton & Woollard, 2019). These problems were recognised by the participants as they navigated some of the negative associations of social media with mental health. Importantly, in their positioning of the “bad”, adolescents provided some balance in their discussion and noted that it was linked to safe practices and volume of use, and separated their personal use from adolescents generally.

Other websites like Facebook, Twitter, Snapchat, like if you use them too much it’s bad for you

P1-London-12-13-years

Some people can’t survive without a phone and they don’t take time to talk to their families

P4-London12-13-years

While recognising some potential negative effects, the adolescents were clear that their access to social media was important to them as without this connection they would miss out and stand out in school as different. However, here we can see that they distance their personal use from others “some people” (not myself) and using the proverbial “you” to refer to adolescents broadly. There were occasions where they used the pronoun “I” and recognised a pressure to be online.

My parents don’t get it, they don’t realise that if I don’t go on social media I feel like I’m missing out

P4-Leicester-17-18-years

Indeed, as seen here adolescents felt that the adults around them did not understand their social world, the pressure within it and the value of the smartphone as part of their lives. As this participant articulated, there is a need to be part of a social community and without the necessary device to connect to that social world there is a feeling of missing out.

Despite the compelling need to be connected through their devices, the adolescents simultaneously recognised that such activity pressurised them and held potential risk for low mood or anxiety.

There’s pressure on stuff like Facebook and Instagram, to get likes on your photo

P4-Leicester-15-16-years

If you see skinny models on the television ….you’ll start to feel depressed about how you look

P2-Leicester14-15-years

I think that nowadays you’re taught to have low self-esteem, like with Photoshopped images and things like that

P4-Leicester-17-18-years

For mental health practitioners, a core concern was the association between mental health conditions and poor sleep. The evidence base is clear that poor sleep is strongly associated with poor mental health (Woods & Scott, 2016), and therefore, aspects of adolescent life that interferes with sleep quality require attention. The practitioners were clear that they regularly heard narratives in their clinics of constant connectivity to poor sleep.

They’ll talk about not being able to sleep and they’ll text at, you know, whatever time and because they’re waiting for that response, there’s no holding back

P1-CAMHS-group1

They won’t sleep at night time, I’ll say to them, the ones who have been bullied, I say well turn it off, ‘well someone might contact me’!

P6-CAMHS-group2

Theme three: the ugly

Arguably most concerning has been the “ugly” aspects of social media. In response, there has been growing public concern and government attention and therefore in the UK an “All Party Parliamentary Group on Social Media and Young People’s Mental Health and Wellbeing” was established in 2018 (Royal Society for Public Health, 2019). In the data, despite their self-confessed constant use of social media, the adolescents still positioned social media as dangerous for mental health; something we have discussed elsewhere (O'Reilly, Dogra, Whiteman et al., 2018).

It’s a dangerous place social media

P7-Leicester-15-16-years

The scope and range of this danger was discussed through various issues that they felt could place adolescent mental health at risk, and that they reported the risk and impact was more considerable than just over use. Predominantly, this danger was constructed in terms of bullying and trolling.

It’s just bullies on the internet, if you ask for help and they’ll say something then you think that no-one will ever help you

P5-Leicester-14-15-years

I feel like cyberbullying plays a huge part in everyday life and that comes mainly from social media

P2-London-15-16-years

If you think a picture is good or other people think it’s funny you might get bullied and you might not tell your friends, or you might not tell an adult, um, that you’re getting bullied on social media

P5-London-12-13-years

Externalised issues like bullying were also considered alongside internalised issues such as self-harm and suicidal ideation, which are argued to be directly connected to social media.

If you’re exposed to a lot of stuff about self-harm and mental illness, it might affect you mentally as well

P8-Leicester-14-15-years

In the past that’s also caused deaths of people being like targeted on social media, and they end up committing suicide

P4-London-15-16-years

While adolescents discussed the risks of self-harm and suicide as related to social media, they did so through third-party attributions, in abstract ways of the general population. Notably, these narratives were not personal discourses or based on personal experiences but were stories or reports that they had heard via different sources. Practitioners did provide more personalised case examples in their discussions of self-harm and suicidal ideation as they had experiences of clients who had encountered these difficulties. This is arguably expected given the connection between emotional mental health conditions and self-harm and/or suicidal behaviours (NHS Digital, 2018).

Thinking of young people I’ve worked with who would send photos of like a text message photo of a box of paracetamol or razor blades and things to a carer or friend, and he amount of anxiety that raises in the person that they’ve sent it to

P2-CAMHS-group1

I mean I’ve had girls who’ve said, you know, they’ve been trolled, and people have told them to kill themselves and then they feel they have to

P1-CAMHS-group1

While the “ugly” of social media encompassed a whole range of problematic aspects of use, not limited to these examples here, the discussions transitioned from considering how these problems impacted mental health, to possible solutions to the problem. The challenge for mental health services is to help adolescents with diagnosed conditions build resilience to the negative impact, question their constant connectivity and foster more positive use of social media in their lives, as one practitioner stated:

I think as a culture in terms of working as clinicians we’d like it to go away, but social media isn’t going to go away it’s only going to become more prevalent in our society and we need to start working with it, rather than against it.

P2-CAMHS-group1

Discussion

Globally we are amid a child mental health crisis, with increasing prevalence of common mental health conditions and serious concerns about the rising rates of self-harm and suicidal ideation, especially in adolescents (NHS Digital, 2018), and the rise in cyber-aggression is strongly linked with poorer mental health outcomes (Mishna et al., 2018). Although the aetiology of mental illness is multifactorial, linked to genetic, familial, economic and social factors (Dogra, Parkin, Gale, & Frake, 2017), there has been a tendency to blame social media for the current state of play. The UK Health Secretary, Matt Hancock, has proposed that guidelines are needed to encourage parents to restrict social media use by adolescents (The Guardian, 2018), reflecting a “moral panic” (Cohen, 1972) when the evidence is more equivocal. However, the House of Commons Science and Technology Committee and Chief Medical Officer in a recent report noted that there is a lack of strong evidence to guide regulation of children’s screen time, and a lack of understanding of the possible intersection between social media and other factors (House of Commons, Science & Technology Committee, 2019). While there is evidence that illustrates some possible negative impacts on mental health, there are also benefits that can protect well-being and blanket restriction has potential to infringe adolescents’ rights and underestimate their digital literacy and competence (Livingstone & Third, 2017).

The analysis in this study revealed that adolescents and mental health practitioners fluidly moved between rhetorically pursuing the virtues of social media for protecting mental health and extolling the dangers of spending time on Internet-enabled devices. Perhaps, most interesting was that adolescents differentiated “them” from “I”, distancing themselves from the possibility of negative impact on their own mental health while expressing concern about more vulnerable adolescents. This may be because of the stories they read in the media (and were citing in the focus groups), rather than any direct experience or first-hand knowledge. In other words, they commonly read the headlines that projected serious impact on mental health and cited those news stories in discussion. Interestingly, they also used Google as a search engine to learn about mental health. This has implications for mental health practitioners, as young people who present in clinic are likely to have “Googled” their symptoms before attending, or conversely may not seek help as they may believe “Dr Google” is their most appropriate source of support.

Practitioners also noted differences between their client group and adolescents in the general population, recognising, like the adolescent groups, that some young people are more at risk than others. Interestingly, there was some congruence across the adult and young person perspectives, with most viewing it as negative for mental health. However, young people thought it was beneficial for their own personal mental health, whereas practitioners, although recognising some possible benefit, overall did not believe it was good for anyone. Furthermore, practitioners felt that time restrictions should be placed on social media use, whereas the young people felt they should have freedom and autonomy to make their own decisions about when and for how long. They believed they had the skills to manage this against other things in their lives and could adequately protect themselves from harm.

Listening to adolescent voices and appreciating the perspectives of mental health practitioners can be enlightening and important for those who work in the field. If practitioners are to appreciate their client group’s use of social media in terms of its relationship to their mental health condition, it is necessary that they remain open-minded as they guide families through the complexity. It is challenging to measure the prevalence of risky behaviour and difficult to ascertain which adolescents are vulnerable to risk (Livingstone, 2013), although research has shown that those with “psychological difficulties” are one group that is potentially more vulnerable to the possible negative impacts that social media may cause (Livingstone & Palmer, 2012). Assessing for risk is a central task in the clinical interview, particularly in the mental health assessment (O’Reilly, Kiyimba, & Karim, 2016), and given the extent of social media usage and their own view that social media can be “dangerous”, it is arguable that social media could be one of the core areas that are risk assessed in these appointments. This would be important as the narrative would be adolescent-driven rather than influenced by preconceived ideas of the practitioner.

Notably, while examining risk is an important activity in mental health practice, the possible benefits of social media should not be underestimated. Data indicated that mental health practitioners and adolescents all felt that that social media and the Internet could protect their well-being, and provide them with valuable sources of information and tips for self-support. With the rise of mHealth, mental health services could create excellent opportunities to better engage adolescents in their care. Furthermore, social media may work as a way of detecting issues, like depression (Michikyan, 2019). Indeed, research on adolescents with mental health conditions has shown a preference for digitally mediated communication with practitioners as this was less anxiety provoking (Rensburg, Klingensmith, McLaughlin, Qayyum, & van Schalkwyk, 2015). However, this needs to be contextualised against mixed attitudes amongst mental health practitioners as they remain divided on the ethics and utility of technology in digital care (Deen, Withers, & Hellerstein, 2013). Media reports and a general negative rhetoric are not necessarily helpful for practitioners working in the field (Bell, Bishop, & Przybylski, 2015), and evidence in this area remains unclear and mixed (Orben & Przybylski, 2019). However, social media is an integral aspect of society, especially for younger participants, and the rise of a digital world carries considerable potential for mental health communication and promotion, and is an area that could be embraced by practitioners.

Listening to adolescent voices is a considerable strength of this paper, but as with most qualitative studies there is a need for a meta-synthesis of voices to provide a stronger transferability and/or generalisability of findings. This study included participants from two large cities in the UK, but this has some limitation. While sampling adequacy was assured for a single study, more work in this area is needed. The qualitative evidence base is starting to emerge and greater emphasis on adolescent voices is needed, but also future research is necessary to better understand mental health practitioners’ views on social media in terms of their patients and the value of having it as a risk assessment item on the clinical interview agenda. Our mental health practitioners were mostly psychiatrists and Community Psychiatric Nurses, but a greater range of professionals who work with children would be beneficial. Furthermore, our adolescent participants were non-clinical samples, recruited through schools to reflect the general population and more detailed work with those young people with a diagnosis could give a different picture.

Mental health practice is a discipline that benefits greatly from qualitative research as it is a practice that relies on language, narrative and adolescent perspectives. By listening to adolescents in research and in practice, a more nuanced, in depth and personalised position on the relationship between social media and mental health can be ascertained. Given the ubiquitous use of social media in this age group, social media needs to be on the agenda and although it is not the case that social media are intrinsically good, bad or ugly, these kinds of issues do need to be considered.

Acknowledgements

Gratitude is extended to other members of the team, including Nisha Dogra, Jason Hughes, Natasha Whiteman and Paul Reilly . The author thanks Seyda Eruyar, Riya George and Liam Voice for their roles in data collection. The author especially thanks all participants for taking the time to discuss the issues in the focus groups.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

The author thanks the Wellcome Trust [109393/Z/15/Z] for providing the necessary resources for this project.