I think we'll jump in for it. So I think we have almost everyone. People are joining. So hello, and welcome. I'm Dr. John Torres, the director of the digital psychiatry division at Beth Israel Deaconess Medical Center and technology expert for the SMI Advisor project. I'm thrilled that you're joining us for today's SMI Advisor webinar, Considerations for the Use of Online Peer Recovery Forms for Individuals with Serious Mental Illness and Substance Use Disorders. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get answers you need to care for your patients. Next slide, please. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one CE credit for psychologists, and one continuing education credit for social workers. Credit for partaking in today's webinar will be available until March 26 of this year. Next slide, please. Slides from the presentation today are available to download in the webinar chat. Just select the link to view it. Hopefully pretty easy. Next slide, please. Captioning for today's presentation is available. Click Show Captions at the bottom of your screen to enable. Click the arrow to select View Full Transcript to open captions in the slide window. Next slide, please. Feel free to submit your questions throughout the presentation by simply typing them into the question area found in the lower portion of your control panel. We'll reserve about 10 to 15 minutes at the end for question and answer, which I will moderate with our speaker. And now the most exciting slide I'll present. Next one, please. I'd like to introduce you to today's amazing faculty speaker, Dr. Jason B. Kolditz. Dr. Kolditz is an assistant professor in the Division of General Internal Medicine with a secondary appointment in the Department of Psychiatry. His research is situated at the intersection of alcohol and substance abuse disorders, which we know are very comorbid in people with serious mental illness. He uses computational social science methods to understand psychosocial predictors of recovery from addiction disorders. He really is an innovator in developing digital behavioral interventions and really understanding how we can use different forms of technology, including social networks, to help people towards recovery in these disorders. I think we all know that technology use is common. The most recent report from Pew Data said 50% of young people may be constantly on social media. And I think learning from Dr. Kolditz how we can understand new roles of technology that may potentially help our patients with SMI is so critical. It's certainly so novel. So, Dr. Kolditz, thank you for leading today's webinar and sharing your expertise. I'm going to hand it over to you until we get to the questions. Thank you, Dr. Torres. It's my pleasure to be here. I really appreciate this opportunity to speak with you all today. There we go. I have no relationships or conflicts of interest related to the subject matter of this presentation. Today's learning objectives. Upon completion of this activity, participants will be able to list three types of social support that are commonly encountered in online recovery forums, identify types of online support that may be detrimental for individuals who are at risk or currently experiencing psychosis, and experience interpersonal deficits consistent with personality disorders. Third, in addition to limiting forum use for at-risk individuals, we will identify two strategies for increasing the safety of recovery forum use for individuals with SUD and SMI. Social media at large. Social media is ubiquitous. Three quarters of U.S. adults use it and a majority of adults get their news from social media. This presents a problem or several problems for our mental health. Time spent on social media has been shown to predict anxiety and depression across multiple studies in a recent systematic review by Lopez and colleagues. Additional evidence suggests that in addition to time spent using social media, dividing that time across a large number of platforms also relates to worse symptoms of anxiety and depression. And while people use social media to connect, they are often left feeling more socially isolated as a result. Social media use also disrupts sleep in multiple ways by displacing time usually spent sleeping and also through physiological processes related to blue light from screens interfering with circadian rhythms. In short, social media seems to be using us as much as we are using it, leading to a host of negative mental health outcomes. However, by integrating principles of media literacy into our technology use, we may defray some of the negative outcomes associated with using social media. As my longtime research mentor, Dr. Brian Primack, would say, we need to keep it real on social media. That was the premise of his recently published book, You Are What You Click. His work outlines four broad considerations for healthier social media use. Considerations for healthier social media use for the general population. So the acronym for keeping it real is RENEG, negativity in social media interactions tend toward positive engagements. Engage actively with social media, but in a balanced equilibrium. We understand that passive use of social media actually has an entirely different kind of impact on active use for people's mental health. Third, attend to actual allies on social media. So ignore the trolls, the troublemakers, the provocateurs, and really get in touch with the people who are there to be in touch with us. And fourth, limit social media use in terms of time, frequency, and number of platforms used. The less social media we use, probably the healthier balance we'll be able to achieve. And these are for the general population. While those general guidelines may apply to populations with serious mental illness, there are other important considerations and potential opportunities for social media platforms as a vehicle for peer support among people with mental illness or addictive disorders. So we know from the literature that peer support interventions may be effective for the clinical and personal recovery of mental illness. While effects are modest, they're consistent. Suggesting potential efficacy for peer support interventions across a wide variety of mental disorders and intervention types. We also know that persons who self-report living with mental health conditions and who engage in online peer support communities were most interested in services relating to enhancing coping mechanisms and skills, enabling overall well-being, and accessing therapy. So while peer support in and of itself can be helpful, the online peer support space can also help and contribute to people seeking out treatment and seeking out in-person support. In online spaces for peer support, there are four core types of social support that we consider. First, instrumental support. So if you think about this in an in-person context, for example, in Alcoholics Anonymous or other 12-step groups, instrumental support often takes the form of service activities. Things like making coffee, setting up tables and chairs, reading meeting preambles. So later in the presentation, we will discuss this type of in-person service work and how that might translate to online VED use. We will also cover three other types of support that are more germane to the online space. Informational support. Informational support. This is largely self-explanatory. It's providing concrete information or instructions to support others' understandings and decision making. Emotional support is also largely what you might expect. I liken it to virtual hugs, pats on the back, and understanding and empathy with other people. And appraisal support is all about providing feedback. Now, this one hasn't received as much attention in the area of research, though I think it has strong implications for online support and for health decision making. So these are the four types of support that are available, and then three of which we will see are pretty prevalent in online spaces. So in a recent study, I searched for these types of support in community responses on Reddit's Stop Drinking forum. Now, while this forum is not representative of all online addiction support forums, Stop Drinking is the most popular and active forum of its type across the internet. It's notable that 40% of responses contained two or more types of support, but none of these responses contained references to instrumental support. For example, money or tangible goods or services being exchanged. Now, this is likely due to forum rules explicitly discouraging users to ask or offer such assistance. Informational support was the least prevalent form of available social support. In this case, this directed users to external resources such as books, recovery meetings, health supplements, non-alcoholic beers and seltzers, and other types of information available outside of the site. So one reason that informational support may be one of the rarer forms of support in online spaces is because the internet is huge. People can Google and get informational support or just information that they're looking for without needing to ask questions in a live online community. So we can expect that as people are engaging in peer support and they're exchanging information, they're probably also likely to be using alternate sources of information such as search boxes to get information on their own. Appraisal support was more common and included over half of responses. Examples of appraisal support included normalizing experiences, saying things like, the first few days are like that in reference to recovery, or slipping up is normal. Behavioral feedback, saying things like, drinking will only make this worse, or I wouldn't do that if I were you. And then rhetorical questions such as, how was that working out for you? Or do you like what you hear from yourself? So you can see that this type of support can be potentially helpful in redirecting others' thoughts or behaviors, but it can also be contentious at times. And finally, emotional support. This is far less contentious, and this was the most common type of support exchanged on stop drinking. I describe it as the easiest type of support to give, since the messages are largely formulaic. They're brief, they're positive, they're easy to read and understand. So some examples of emotional support in this community are general encouragement, just brief notes, congratulations, congratulations, congratulations, congratulations, congratulations, great job, you got this, you can do this. Empathy, oh, that's terrible, I feel that, I'm sorry to hear that. And in this particular community, we identified a common catchphrase to indicate alliance, which is this kind of alphabet soup of an acronym that you see on the bottom here, which stands for, I will not drink with you today. And in this community, this was something that was offered as a standalone response. If someone was having a difficult time, someone might just respond with IWNDWYT, or it might be kind of used as a sign off or as a greeting in this community. And as far as we know, this is unique to the stop drinking community. So this is also interesting because it gives a sense of kind of place and a sense of social connection. There are kind of these rules and mores that people are following that help them identify with a particular community. So I did an earlier study of stop drinking, and this was part of my doctoral dissertation. And in this study, I examined new users' activities, including engagement patterns and content of messages that predicted sustained engagement on the forum. Now, sustained engagement was important to consider because roughly half of new users on the forum did not return after an initial engagement. This, of course, greatly limits the possibility for continued exchanges of support. Relatively few new users sustained weekly engagement through the first one to three months after an initial engagement. However, the odds of engagement were 13 to 20 times, 25 times higher among new users who responded to other posts within their first week. This could indicate that engaging for the communal benefit helps to solidify individual commitment and cohesion within the community. And this strikes me as similar to how the service activities are often recommended for newcomers of in-person 12-step groups, as we had talked about with instrumental support early on. So while there are no opportunities here to provide that type of support, like making coffee or setting up tables, providing support through commenting serves as a valuable purpose and resource for both the community and the individuals who are engaging there. So this is good news for the community and individuals, because across time, commenting was far more common than posting on Stop Drinking. So that is, people were less likely to post spontaneously and seek support as much as they were more likely to be responding to other people's posts and providing support to others. So while new user activity dwindles over time, the influx of many new users, as well as sustained efforts of moderators and veteran users, maintains high activity levels in this community. And this pattern illustrates a highly active, responsive, and thriving online community. And this also means that the stakes are low for new users. They can drop in or drop out with much overall growth in their community. So in practice, I wanted to sort of wrap around some of these and think about how, as clinicians, we might consider or approach this with patients. So we understand that online recovery forums can serve as sort of a virtual sandbox where patients can develop and share their experiences. And we understand that online recovery forums can serve as sort of a virtual sandbox where patients can develop and practice social support skills in an informal peer recovery setting. So as we mentioned before, it's low stakes. Now, this would be preferable to more general patterns of social media use, as we discussed earlier in the slides. Now, on some social platforms, such as Reddit, it's also common to start over with a burner account, meaning that activities can be kept more narrowly focused on a particular health condition or life experience. And then when the person is done with that experience or they're done with this particular platform, they can burn the account or start a new account. And that offers a lot of, I think, security for folks that they understand that the account isn't permanent. While it's committed to the internet and the internet is forever, their name isn't necessarily associated with it. And they can start over if they had a bad experience or if they needed to move on. So what I suggest is that we ask patients about their social media use patterns, because this is going to be important for their overall mental health, and that we exercise clinical judgment about recommending online support activities. Not all online support activities are going to be positive, as we'll see in future slides. And some types of support could be problematic in various contexts of serious mental illness. So some psychoeducation is warranted for people who are not in a good mental health situation. And for clinicians to pass this information on to patients who are using online resources. So special considerations for SMI populations. Patients with serious mental illness who use online forums for addiction recovery require further clinical consideration. For example, patients with symptoms of psychosis or delusions, such as in schizophrenia or in manic episodes, may misinterpret common online information or fall prey to misinformation online. Patients with symptoms characteristic of cluster B personality disorders, such as borderline personality disorder, may face substantial interpersonal challenges in online spaces. And patients with severe depression may be lurking in forums, that is reading but not actively engaging, which would limit the amount of social support exchanged. So in the context of depression, the suggestion might be to encourage more targeted and active use when possible, perhaps emotional support in particular. While there isn't a strong literature on lurking in recovery forums for this population, even this passive behavior may be preferable to alternate modes of social media use that we know can cause significant issues and are associated with, you know, greater depressive symptoms. And then with respect to psychosis and personality disorders, we can at least draw some inferences about how these clinical features might be impacted through different types of social support. So over the next couple slides, we'll go deeper into those two areas. So for patients who experience psychosis, the research indicates problems with information processing, particularly related to delusional thought processes that can lead to impulsive decision making in daily life. So receiving informational support may be particularly problematic for these individuals in online forums. This challenge is magnified by the presence of various spiritual practices that are encountered and encouraged in recovery settings, as well as the presence of misinformation or disinformation that is commonly encountered online. So in this example, we think about these three types of support. Informational support, especially around kind of spiritual topics or things that may be misleading or misdirecting, could be a real challenge for this population. Appraisal support is more of a double-edged sword. So it could reaffirm or it could challenge delusional thoughts or patterns of thoughts around topics related to recovery. And emotional support seems generally wholesome and okay in this context, right? It may be helpful while exhibiting limited risks of contributing to delusional thoughts. So the types of support here for psychosis that might be most problematic are going to be different when we start talking about personality dynamics and personality disorders. So for patients who experience symptoms consistent with cluster B disorders, the research indicates extreme emotional reaction to perceived rejection in online chats. Now such reactivity is likely to undermine a patient's intention to remain engaged in online support and it may lead to challenges encountered in the community. Appraisal support in particular poses multiple challenges. So if the support is perceived as critical, it could trigger this type of emotional reactivity. Even if the support is affirming, it may reaffirm self-limiting beliefs or it may hinder self-reflection. So appraisal support can be a real challenge in patients who are experiencing symptoms that are characteristic of personality disorders. Informational support, again, a bit of a double-edged sword. It may be innocuous, it may just be understood as information, or it could be perceived as rejection if the information runs counter to prior expectations of what they're expecting to hear in response. And again, emotional support, good, wholesome, limited risks of perceived rejection. There may be other potential issues related to sort of attention-seeking in this population, but by and large, it seems that emotional support of the three types of support here would be potentially most beneficial. Okay, so I'm going to switch from the kind of clinical picture, and we're going to talk a little bit about today's resource. Now, this resource wasn't developed specifically for SMI populations, but I hope that it can be helpful for you and your patients, especially patients who are considering using online support in recovery related to SMI, related to substance use disorders. So I would invite you to explore the NEAR-FAR resource and also provide feedback to me so that I can tailor it to be more inclusive of diverse patient populations. I am very much looking forward to feedback to help enhance this resource over the coming years as well. So NEAR-FAR currently has three main components, recovery topics, rules of the road, and the forum dashboard. So overall, these provide educational resources about addiction recovery, online forum use, and safety and privacy. There's an interactive dashboard listing that includes recovery forums and their basic characteristics and activity levels so that providers and patients and researchers have an understanding of the landscape of what's out there and can make more informed decisions about what forums might be appropriate for particular individuals. And the resource is intended to be appropriate for clinicians and some patients. Of course, exercise clinical judgment in recommending patients go there. And while we've done our best to kind of keep it at a reasonable level of reading and understanding, some of the topics can be a little bit heady. So it's recommended that if patients have challenges sort of understanding more complex topics, that probably a clinician or someone who's close to that patient would be able to be available and help to understand some of the more complex topics. So some rules of the road. And this is one of the modules in the NEAR-FAR guide. And this, I think, was one of the more important ones. And we got this information from looking at a host of online forums that are out there and getting a sense of how they recommended that people protect their privacy and their safety online. So first and foremost, of course, is to be cautious with medical advice that you get from people online. Always consult with the doctor about safe and effective ways to manage alcohol and drug detoxification or any other health decision making, of course. But we do worry particularly about people who may want to cease use of alcohol abruptly or opioids abruptly because the profile of withdrawal for those can be life-threatening. And then, of course, with other substances, there's going to be a withdrawal period that online resources can be helpful for people to understand and get a sense that they're not alone in these periods of acute withdrawal. But it's important to not take medical advice from strangers online. Of course, avoid sending money to strangers. Watch out for potential scams. Don't click on links from suspicious sources. This applies kind of to the internet at large, but certainly there are people who may want to target online communities where people are vulnerable. So it's good to be particularly aware in this context. Many forums require you to register using an email address. So when discussing sensitive topics, it's a good idea to consider using a separate email address, not connected to your personal accounts, not connected to work. And this sort of goes hand in hand with when we were talking about Reddit forums, people have burner accounts. Those burner accounts could have burner email accounts, and that gives extra layers of kind of security and protection for individuals who are discussing sensitive topics online. And avoiding posting personal information such as full name, phone number, address, birthday, etc. These details can be used to access accounts or steal your identity. As we'll talk about in a couple slides, some of this doesn't apply if people are using forums on Facebook where their name and picture is already associated with that. And that gets into other issues of kind of privacy versus anonymity that we can talk about. Okay, so across the landscape of these, you know, over 200 forums that we catalog that were online, we first looked at sort of the big platforms, right? So Reddit, 18% of all of the forums we found were on the Reddit platform. 14% of all of the forums we found were on the Facebook platform. And then there are additional kind of platforms that serve as hubs for online forums. And then there were a number of online forums that were just in standalone locations. So they were either set up as a blog where people can post and respond. And largely those ones were going to be less active than ones like Reddit. Reddit forums were largely the most active of all of the forums that we found online. Facebook was a little less active. However, Facebook does have better privacy around their forums. So when we're thinking about different platforms where these forums exist, all of the websites are going to have a little bit of a different flavor or profile around how the forums are set up. So for Reddit, for example, everything by and large is in public forums. And there are some private forums that are buried. They're hard to find. People generally aren't going to run across them. But when people are posting in Reddit forums, they're going to be posting in Reddit forums. It's available for all of the internet to read. So it's important to think about anonymity in this context, right? We don't want people using their names. We don't want people putting their dates of birth. We don't want people to really out themselves in certain ways when all of what they're writing is going to be like public knowledge. Now the upside of that is this is a real wonderful compendium of information. So when people are facing questions about recovery or questions about mental illness, and they search on Google, one of the first sites that pops up near the top of the search results is Reddit. And people will find that probably this question may have already been asked in a similar way. And there's probably been a discussion around it. And sometimes it may be appropriate to piggyback on one of those discussions if it's a recent one. Or it may be appropriate to post a new post, you know, if there's additional clarity that they're seeking and they want to get that type of support from other people. Now in Facebook, it's different because Facebook is really widely used, especially in kind of like not as much in like adolescence anymore. I think the adolescents have kind of moved on to TikTok and other platforms, which we're not going to get into sort of the video online support in this presentation, which it's an interesting topic and one that we're going to continue looking at. But for Facebook, you can sort of think about that of like, you know, this is people's aunts and uncles and families and friends, people they went to high school with. So there's a real concern that what they post there may not be appropriate for that whole kind of population of friends and family. So in this case, the Facebook groups tend to be private, in contrast to Reddit groups that are publicly visible, available. So in theory, people, the friends and family wouldn't know that a person is like participating in one of these sort of private forums on Facebook. Now that sort of comes with, you know, again, this balance of, you know, privacy, anonymity, where's the comfort zone. Sometimes it's maybe better for patients to not use the flagship social media platforms and to explore other venues. You know, there are places, addiction recovery guide, that's going to be like more specific places like, you know, the drug abuse forums, daily strength, med help, psych forums, and these will, again, all have a little bit of a different flavor. There are sites where people will be able to ask more medically oriented questions and get sort of peer feedback or get feedback sometimes, but rarely from someone who's licensed to, you know, provide that feedback. By and large, what we found is that like among these forums, this is very much a peer oriented community resource. So there's limited clinical supervision over what's going on in the forums. And we'll talk a little bit more about that in the next slide, I think. So the overall landscape of addiction recovery forums from our recent research, most of the forums that are out there, we cataloged as non-specific. So they weren't targeted to a particular substance. It was just about recovery or about overcoming addiction. After that, they were primarily directed toward alcohol use disorders. And you can see non-specific was about half of all of the forums we identified. And then, you know, about a fifth of the forums were specifically related to alcohol use. Most platforms, 91% of them do require signing up for an account to engage. And a lot of times that requires an email address, giving some personal information. So again, going back to how can we protect people's privacy anonymity in these spaces is, you know, using alternate email addresses, using pseudonyms as names, if there are concerns about privacy. And then also keeping in mind that these forums aren't, you know, professionally moderated. There aren't licensed clinicians by and large that are in these forums. And if they are, they may not identify as such. So keeping in mind forum moderation is very much kind of a community and peer-led initiative. And some things may be less rigorously moderated than others. And a lot of that depends on where the forum is and kind of what that community ethos is. There are several forms for specific populations. Now, this is important for folks who have or feel strongly about religious beliefs or spiritual beliefs. In recovery, we understand that some people prefer to not go into kind of like the 12 steps, spiritual models. Some people really do prefer to have that as part of their recovery pathway. So it's important. And this was something that we fleshed out in the dashboard of like, which of these groups were more spiritually oriented or for specific religions. And then also forums for diverse populations. You know, we did run across forums for the Sober Black Girl Squad. We ran across a forum called LGBTQ Plus Forum. And that may be appealing for people that are, you know, in those categories and that are also seeking support for addiction. I should note that there weren't forums specifically for addiction and comorbid SMI. And there are forums that are related to SMI or other mental health conditions. Those aren't part of this particular compendium. Now, what we're focusing on here is really the substance use aspect. There may be other appropriate forums to keep in mind for patients whose primary challenges relate to mental health issues. And then maybe like substance use is more of a secondary challenge. And then also with respect to gender, with very few exceptions, forums specifically for women did require a paid subscription. Now, this was an interesting finding from the paper. And it led to a little bit of a rabbit hole about understanding like female entrepreneurship and how that led to these kind of startups where really women galvanized around recovery and a shared identity. And also that there's a sense that this keeps out maybe some of the riffraff by having a minimal and in some cases an expensive, you know, fee to pay to join the group that people are going to be more committed by virtue of paying for membership. And also that it will keep people who are just there to cause trouble maybe further out of their orbit. But of course, you know, that does present a barrier. And that's a concern that we have of the women's only groups aren't going to be as easily accessible necessarily as some of like the broader groups that are on social media like Reddit and Facebook. And I got through quite a bit and a little bit faster, I think, than I was anticipating. So we're going to have some time for questions and answers. These are just the references. And I think I pass it back to John at this point. Excellent. Can we go back one? I think we have the or we'll go forward one slide. Sorry. So perfect. So we'll get to Q&A in just a moment. And I you can put more questions in the chat somehow come in already. But before we shift to Q&A, I want to take a moment to let you know that as my advisor, we have an app, we're talking about technology, this is definitely very appropriate. It does not have a social component quite per se. But you can do a lot on the app, successful for your mobile device, you can access resources, education, upcoming events, you can do mental health rating scales, and even submit questions directly to our team of experts. And you can get the app on Android and iOS devices at SMI advisor.org slash app, as you see right there. So useful, handy tool. Maybe we'll advance to the next slide. And we'll do some question and answer. So one question that came up, or actually, I'm gonna I'll cut the line and use my own first. And I was last week admitting a patient with bipolar disorder to our inpatient unit. And he said, Dr. Torres, we need to finish the admission orders a little bit later, because I need to attend an online group. It wasn't AA, they said I'm using an online group for substance support. It was from I hadn't heard of this online group before the patient said it's been very helpful. With my alcohol use disorder. These are a bunch of people I really can connect with. And we always meet at the same time and I need to do it. How Dr. Coles do I as a provider and clinician and clearly, I, I said you should do this. It's important. But how do I know, or get a sense of is that a useful thing? Is he getting bad information from the group? I'm not here to go watch what he's doing on the internet or as a privacy line. But how, how do I know this is helpful? Or is he actually getting misinformation from or if so, I guess the question is, someone says they're using a thing. It could, what do you, is that helpful? Is it harmful? Do we have any clues to kind of tease that apart? Excuse me. Yeah, that could be difficult. And, and it really is going to depend, I think, on the patient's perception of what they're getting out of the group. You know, we know that social support can be such a critical aspect. And peer support and having like relatable experiences can be really helpful for folks who are going through a process of recovery or coming through addiction, even if they don't identify as in recovery. Certainly understanding other people's experiences and reflecting on their own experiences is, is hopefully going to lead to some level of understanding that helps them work through, you know, the bumps in the road and some of the challenges. I, you know, one of the big challenges in this area of research is we really don't have like rigorous clinical trials about people using online support, you know, video support, and even much less the kind of text forum support that I'm researching. But what we do know from kind of not only anecdotally, but from cross-sectional studies and from qualitative studies is that people do find a great deal of value. And they are able to bring this into the sort of clinical space and come back with more information and kind of a sense of understanding and reflection based on what, what they're putting out there and kind of what they're getting back from the communities. And the, the scene really has changed, I think, since COVID in that video meetings are really becoming more kind of the norm. And it seems like that that may potentiate people getting into in-person, you know, support, if that can be an entryway to that, which would be a good, you know, we, that's still the gold standard, the studies and research that have been conducted up to this point about 12 step or similar groups are largely on in-person support where there's coffee and hugs and tables and chairs. So we're kind of in this brave new world now of how does this equate to online support? And one thing that I like to say is that, you know, you're getting some benefit more than likely from these sort of online engagements, some social benefits, some insight. But the other benefit is that it can lead to the sort of gold standard of someone showing up and making, that's a big step, you know, for someone to show up in a church basement and really put themselves out there. And this is again, sort of can be a sandbox for that. So I guess as a, to put myself in sort of clinicians shoes, I would really want to ask them, you know, how, how has that experience been? Have you learned anything new? and particularly, you know, kind of targeting questions toward their particular conditions, in this case for like bipolar, would, has their experience been different on some days versus kind of other times, you know, when they're kind of in a depressive episode, their, their engagement may be quite different than if they're, you know, in a hypomanic or a manic episode. And that might be another way to sort of work into their understanding of how, how this forum is working for them. Well, thank you for an answer. I also feel good because those are some of the questions I asked the patient, and we did agree it was important for him to attend that kind of social media kind of, or phone app-based visit during his stay in the inpatient unit. So I think it's something that clinicians are encountering more and more. One question I'm seeing, too, is as we're sending, again, I won't say sending people, as people are finding different forums and resources on the internet, it can be personalized, helpful. We don't control all of the language, clearly. So this question says, thinking about language, can you speak to issues such as using terminology like personality deficits, which we all agree is unhelpful, but sometimes, right, you, you look at these forums and you see language that is stigmatizing, incorrect, sometimes wrong. And I don't think anyone's trying to harm each other, but there's just different terminology and different ones. And how do you, do you caution people about that before they maybe look for them? Do you, is that just kind of the cons we have to be aware of in this? Or it's, it's a big world, as you said, the internet. I'm writing this down because I think this is something that ultimately is going to need to be added to sort of the near, far, as one of these rules of the road. So sort of cautioning about stigma, because this really is an issue, I mean, across the internet at large of, you know, lay language can be very pointed, dismissive, and, you know, bordering on, I don't want to say bordering on, just like very stigmatizing, you know, in some communities. Now, what I'm seeing in at least the communities that I'm looking at in, in these studies is it's pretty innocuous. It's not the type of stuff that you're going to find in like in the wild on the internet where people are calling each other crazy and, you know, far worse than that. But there, I think the more that people get involved in these spaces and people who are like genuinely growing and understanding about recovery, about mental illness, they do tend to kind of self-correct or, or help to sort of correct each other when things might get a little bit too, in that area of kind of like heavy stigma. But it is something that should be addressed, that people will go on there and they may feel triggered, they may feel attacked that, you know, the language that other people are using can be, can be pretty, pretty brutal at times. And again, moderated communities can be helpful in this regard. So if a community has a good sort of moderation team, if they're keeping on top of those things, that some of those messages will appear and then kind of go back under the radar fairly quickly. And the people, if they're sort of repeat offenders of, you know, being, being stigmatizing or, or, you know, being hostile, ultimately we hope that sort of the moderators are going to take them out of the mix as, as that happens and sort of encourage more of this positive aspect. But that being said, I don't want to be too Pollyanna, right? Like this is an issue. Stigma is going to be an issue there. And I think it is prudent for us to let, you know, our, our patients and clients know. And I think it'll be prudent for me to add a disclaimer about that, I think on the, on the resource as well. So that's a great, great point in question. Thank you. And related, one thing I learned from you, Dr. Koldis is just even asking my patients with SMI, have you tried any of these online forms? I kind of can, you can bring it into your kind of intake. You can say, have you tried any medications? Have you tried therapy? Have you tried online forms? You can almost normalize it as part of the intake. And then you do see patterns and maybe regional what people may be using, say where I'm in Boston, but it is a good way to then get some clinical intuition. At least I know if I have five patients that say they're on, I'll make an example, recovery record, and they're not, they seem to be doing well, I can have a little bit more confidence, not full confidence in it. But as you, I think your example of how you can kind of talk about it is useful. And that kind of brings up a related question of you, you quickly shared kind of, you guys have developed this kind of interesting, I'm going to call it database, right? Of these forms and how to use it. Maybe we can put the link back in the chat because the question was, is there a solid waiting resource of various online forums as providers, of course, cannot possibly check out them all. And how would you recommend people use the link we're going to put in the chat that we covered? And how would you recommend they not use it? What are the rules that erode for using it? Yeah. I mean, I think that I would recommend for clinicians to take kind of gloss through it and get a sense of what's there. The first section of it really is about recovery. It's a little dense. It's a little heady. We're talking about not everyone is in recovery, but if you're in recovery, that's good. Defining some of the kind of key terms that we're using. Going into this space. The rules of the road are really meant to be the most helpful, I think, aspect before people dive into online forums. And really that's just like, cover your bases. Don't trust strangers. Don't take candy from strangers. All of the things that we're going to tell people to keep them safe. And then in the forum dashboard, right? I call it a dashboard. It's a database. It's had a few different iterations. And that's an ongoing process too. We're still populating. We're still updating. We're thinking about other categories that could be there, but it really is like sortable in a way that if a person has their largest concern is like alcohol, they can be like, okay, I want forums related to alcohol. And if they want something that's like spiritual or non-spiritual, they drop the box down, spiritual, non-spiritual and things like that. And that's going to narrow the scope of really like what people are looking for. Because no one wants to look at 200 plus forums just to like find that half of them are inactive or like very low activity. And some of them are like maybe too active. And that's something I probably should have brought up in the discussion. And I think I had notes about that and I maybe didn't get to them, but like you can't judge a forum by its level of activity either. So like looking at Stop Drinking, it's this flourishing, really active forum. The downside to that is people get lost, right? And people kind of drop out without anyone noticing that they've dropped out. Whereas in forums that have more of a steady pace or forums that might be a little slower, people can develop sort of closer relationships where if you're posting a few days and then you go missing, someone might email you and let you like ask you, are you still out there? Are you coming back? So that in terms of sorting things, they are sorted by how frequently they're used, how many users there are like active on the forums. But that doesn't mean to like start at the most active forum. I think it can be important for someone who's never used a forum like that before to maybe the highly active forum is a good place because you get more responsiveness, quicker responses. And if you feel like you need to get lost a little bit in the shuffle, like it's low stakes, right? But as people progress and they really want more kind of intimate support or more detailed support, or they want people to know if they go missing, then moving to a forum that has maybe a more moderate or lower activity level might also be a good idea. That's very practical advice. A related question I see is, can people share this link directly with patients or people seeking help, or is it only to be used by clinicians or peer providers? Use it as you feel appropriate. If you think that it would be appropriate for a patient to kind of go through and read through some of that. And if it's good for them, then it's good for me. I'm happy to have the information shared and be out there. That's why we built it. We want as many people to get this type of support as possible. It's not a perfect resource. It's still in development, as I noted, but I think it's a good enough kind of jumping off point for some people, definitely for clinicians, for researchers to get a sense of it. And if you have a patient that you think this would be good for, send the link. If you want to send it to your whole clinic, send it to a whole clinic. That's at your discretion. It's out there. It's on the internet. And a related question is someone saying, some patients would benefit from attending AA or formal groups that aren't yet ready to engage or even kind of actively partake in post online. But is there a benefit to watching or sometimes an internet lingo lurking for patients? Would you ever, we know there's not a lot of data on it, but is that something you would think could be productive for people or should we push them to go all the way? Ah, that's such a great question. And lurking has really been one of the toughest areas in this space to get a handle on because we don't, we can't observe people if they're not active in the space. The surveys that have gone out around online digital health aren't really assessing lurking in a great way right now. So we really don't know how many people and how long they are just passively using or observing sites before they decide to dive in. There is some literature that says that like, this is an important step or a component in the process of like understanding the community helps to get you ready to give you a sense of what is the normative behavior there. You know, seeing those acronyms helps to sort of go in and you say, oh, I know one thing about this community. If I can use this acronym, I'll feel or I'll be perceived as someone who's in this community. So you can't do that without at least doing a little bit of homework first. And I also think about it sort of in another way of like, we're all, not all of us, but I think by and large, you know, people are lurking in all kinds of places on the internet, right? We're just, you know, scrolling through, you know, reality TV and all of the other stuff that's going on there, just kind of passively consuming media. And I think if, you know, we're passively consuming media that's related to bettering our mental health or that is helping us to understand our conditions a little better, then that's probably a good trade-off. So I think if someone's just scrolling through TikTok for cat videos, like that's okay too. Sometimes we just need those little, you know, bumps of dopamine in our lives. But I think also sending people into, you know, into the shallows a little bit of lurking or passively observing in online recovery spaces really gives a sense of, you know, stepping into maybe posting later or maybe, you know, even better like responding to someone and just giving a stranger on the internet, like you can do this. I support you. And emotional support to me is like that first step. And the research is ongoing here, but I think from lurking to maybe getting your feet wet, giving a little bit of support, and then like when times are tough and you have a big question to ask, you'll be prepared to post that out there and get support, you know, get sort of reciprocal support. So yeah, lurking is, I think lurking is a good thing in my mind. Definitely a relatively simpler step for some people, as you said, that may be needing help with substance abuse, but want to kind of take that first step or moving even towards readiness to change. A related question is, let's say you have a patient who tells you they're going on to an online forum. And then a couple weeks later, they say, I've stopped using it. And you kind of show us some very good data that people don't stay on these things often forever. It can be short. Is that a bad or good thing? Or does that mean they got everything they need out of it? Should we be encouraging them to stick with it? Or I guess, what do we do with engagement? Yeah, that's an excellent question. And that is probably a question that I'll be trying to answer for maybe the next five to 10 years, in terms of like driving the research to understand like, what's the normative pathway that people follow in terms of, okay, they're past lurking, they're engaging, they're engaging about weekly. And that was kind of arbitrary. But that was the rule I used for like consistent engagement, like at least once a week, just pop in, do something, comment, post, whatever. And even at that rate, you know, by one month, we're down to 5% of the people, right? By like, three months, we're down to like 1% of the people. So it's totally normative that new users are going to be like really engaged, and then kind of drop off. And the question is, like, is it just we're expecting too much, maybe one post a week is, is not what they're needing. Maybe it's just crisis posts, right? And like, when things are really difficult, they might post like once, once a month or less. Or is it really just it's kind of a slippery slope, and people fall off really easily if they're not engaging more and more and more. And there probably are going to be individual differences. And I know this is a little bit of a cop out that like, you know, different patients, different sort of personality types are going to be more extroverted, introverted, and are going to have different sort of social challenges in how they're engaging there. If it's causing a kind of social anxiety, that's something that's clinically relevant, right? And that could be discussed with a patient of like it, why aren't you posting any more? Did you get what you felt like you needed? Would it be more appropriate to try a different community, a faster paced community, slower paced community? Would it be appropriate to maybe step into an in person community at this point? Or is it just kind of this is the pace of things and it's causing maybe some anxiety or some other other challenges and then sort of dealing with those, the more kind of clinically relevant, relevant challenges around that. Yeah. And I think, as you've said before, many times is substance abuse treatment takes an entire team. It takes many supporters. And this question goes to family members are, of course, critical towards recovery if people have them. Are there any online forums or resources you've seen for family members or supporters of people that you think are potentially beneficial or worth noting? Yes, they do exist. They're not in this particular resource. It wasn't something that we had within scope when we were working on the project, and it wasn't something that we were funded to do, like the family support aspect. But this can be so important. And I think that we're aware that there are groups like Al-Anon. Al-Anon is online. They are very online. You can find those forums. That might not be for everyone. There are other forums on Reddit. It would require a little bit of kind of searching around. But I've certainly seen forums for family members of people, particularly people with personality disorders. Family members go online to sort of get support to understand what their loved ones are going through and how to adapt and how to support them. And then there are absolutely going to be forums related to family members of people with substance use disorders, primarily. One of the challenges there is getting advice online about complex family systems is another real concern and sort of challenge that we face, is that we don't want people necessarily to take something from someone else's experience and family and try to apply that or fit that onto a whole different family dynamic that's going to be drastically different. So I think that actually adds layers of intricacy when we start talking about family dynamics in addition to sort of the individual dynamics. I think I would recommend, certainly, if loved ones are open to getting that type of support, that they should certainly seek it out. But the research isn't there just yet to say if these online forums are going to be more helpful or more of a hindrance or, again, what sort of individual differences might flesh out. I think that's a comprehensive answer. Sometimes I send people to the NAMI forums, which can also be useful. But let's actually advance to the next slide because we are running short on time and I want to make sure everyone gets their credit in a couple quick updates. So if there are other topics in the webinar that you would like to discuss we didn't have time to, you can post comments to SMI Advisors Discussion Board. This is an easy way to network and share ideas of other clinicians who participated in today's webinar. If you have questions about this webinar or really any topic related to evidence-based care for SMI, you can get a personalized answer within one business day through our national team of experts. This service offers consultation available to all mental health clinicians, peer support specialists, administrators, or anyone else in the mental health field who works with individuals with SMI. It's completely free and, as I said, confidential. We'll go to the next slide. I think what's so exciting about SMI Advisors, there's so many different resources to explore on the website and we offer many evidence-based guides. One I want to highlight here is guidance on stimulant use disorder, such as the basics on substance use and serious mental illness. These fact sheets provide an overview of relevant background details and reviews on screening, interventions, treatments, and more. Topics include alcohol, benzodiazepines, cannabis, opioids, stimulants, and tobacco. You can access these fact sheets by clicking on the link or looking at the download slides there, but they're well formatted. They have great information up to date, so something definitely to look at. We'll jump to the next slide. To claim credit for partaking in today's webinar, you need to have met the requisite attendance threshold for your profession. After the webinar ends, click continue to complete the program evaluation. The system then verifies your attendance for credit. It could take up to an hour and can vary based on regions and your platform, but usually you should get your credit checked off pretty quickly. I want to go to one more slide. Please join us next week on February 1st as Dr. Steven Segal presents Utility of Outpatient Civil Commitment. Again, this webinar will be February 1st on 3 to 4 p.m. East Coast time, so a little bit earlier in the West. And with that, I want to thank everyone for joining. Thank you to our speaker, Dr. Kolditz. Take care.

online peer recovery forums

serious mental illness

substance use disorders

social support

specific needs

challenges

risks

positive interactions

Near FAR resource

clinicians