For many adolescents, more time at home during the ongoing coronavirus 2019 (COVID-19) lockdown has meant more time glued to a screen. Social distancing and limitations on daily life during the pandemic have left social gaps to be filled by the constantly evolving offerings of the internet.1-2

Even before the pandemic, the starry-eyed optimism about social medias ability to connect people across space and time was beginning to wane, even among Silicon Valley insiders. A sense of exploration and possibility has been reduced to anxiety about our rising reliance on technology, especially its effects on child and adolescent development.

Concerns about social media have been infused with a growing sense of unease and vulnerability brought on by the pandemic with the Centers for Disease Control promoting both breaks from social media to reduce stress and using social media to connect with others.3 Early studies from China appeared to show links between social media exposure and poor mental health, including depression and anxiety.4-5 Studies based on social media posts have allowed researchers to identify elevated psychosocial and support seeking expressions online this year compared to the preceding year.6 However, this finding could point to either increased use of social media to convey personal feelings or rising rates of psychological distress.

A recent report by the Kaiser Family Foundation noted that adolescents may be at a higher risk for poor mental health outcomes during the pandemic due to increased loneliness and isolation, as well as a lack of access to mental health resources while schools are closed.7 Being stuck at home could compound parental stress and lead to confrontation.

Vicki Harrison, MSW, Program Director, Center for Youth Mental Health and Wellbeing, Department of Psychiatry and Behavioral Sciences, Stanford University, stated in an interview, Many activities that are good for mental health are difficult to engage in under shelter-in-place orders, such as spending time with family and friends, milestones and celebrations, engaging in extracurricular interests, exercising, and interacting with nature.

She also noted, While young people are resilient and adaptable as a whole, their wellbeing is somewhat dependent on the circumstances of their family life and who they are engaging with during the shutdown. In other words, some adolescents may escape negative experiences at school, whereas others may be forced into difficult situations at home.

During the pandemic, social media may provide a healthy substitute for regular social interactions and a break from home confinement. Furthermore, it may be difficult to separate the effects of social media from the multitude of stressors related to COVID-19, from loss of life to economic decline.8 Adolescents are likely to spend more time online as a result of COVID-19, and coming to terms with societys reliance on online platforms during this time may help parents, adolescents, and others use them in more healthy ways.

A Sisyphean Struggle?

Social media can be a double-edged sword, and concerns about social media may in fact reveal how little we know about emerging platforms of social connection and the inventive ways that young people use them.2,8-10

The relationship between social media use and poor mental health may have been more robust in the 1990s and early 2000s, when less adolescents used them, according to Candice Odgers, PhD, a developmental psychologist at Duke University and the University of California-Irvine. As these platforms have become ubiquitous, findings have become more modest, pointing to little or no negative effects with moderate use.9-10

Amy Orben, DPhil, of Emmanuel College, University of Cambridge, refers to recurring societal anxieties about adolescent social media use and mental health as the Sisyphean cycle of technology panics and argues that psychology plays an integral role in fostering them.11 By analyzing historical responses to other forms of media, Dr Orben noted that panics often lack an overarching theoretical paradigm, recommending that researchers transform their approach to focus on styles of use particular to certain technological modalities, as well as effect sizes and their directionality.11 This new methodological framework would be less reactive and prone to paranoia about the activities of teenagers.

In a similar vein, Dr Odgers promotes looking at transition periods, when adolescents start using social media regularly. She noted that finding control groups may be difficult, as few adolescents are offline, and behavior may change while abstaining for short periods to facilitate studies.10

Online But Not Nave

Although adolescents are often portrayed as unwitting participants in a dangerous social process, they frequently understand the risks of using social media and play an important role in shaping how emerging platforms are used and constructed. Studies based on the perspectives of adolescents reveal that teens are often consciously aware of social media as a potential threat to mental wellbeing, including through cyberbullying and smartphone addiction.12-13

Harrison noted that adolescents are often frustrated by the negative aspects of social media, including hate speech and bad behavior, emphasis on highly curated images and narrow standards of beauty, notifications, ads, triggering content, and design features promoting endless scrolls and viewing. She adds, Many older adolescents have adopted strategies to manage their mental health and balance their usage, whether by taking social media breaks, changing their settings, or avoiding certain apps.

In some cases, life online can offer adolescents healthy opportunities to engage with each other about their mental health. Patricia Cavazos-Rehg, PhD, a professor of psychiatry at Washington University School of Medicine in St. Louis, Missouri and principal investigator for the iCHASM research team, stated in an interview, Online communities do help teens vent and network with others anonymously, which can be very important, especially when communicating about highly stigmatized topics including mental illness.

In a paper, Dr Cavazos-Rehg performed a content analysis of depression-related tweets and found that supportive or helpful tweets were highly common, followed by tweets disclosing depressive symptoms.14 These expressions of poor mental wellbeing may open the door to treatment or facilitate links to care, either through formal resources or online communities.

Online spaces create many exciting opportunities for youth to experiment with creativity, self-expression, and play, said Harrison, They can also be places to find support for mental health, including connecting with others who share similar struggles and experiences affording anonymity.

During the pandemic, social media may offer adolescents a place to discuss their challenges, and openness about mental health online is better than bottling their distress. In these challenging and stressful times, Dr Cavazos-Rehg noted that social media can be fun and distracting.

However, Dr Cavazos-Rehg also harbors some concerns, acknowledging that it can be easy for young people to engage with potentially harmful content and/or to immerse oneself in distracting and time-consuming online activities that could lower emotional wellbeing, including excessive engagement, avoidant coping strategies, and compulsive checking. During a critical neurodevelopmental period, Harrison noted, adolescents may be vulnerable to risk taking, impulse control, fluctuating self-esteem, and peer pressure.

A Mentalizing Approach to Adolescent Struggles Online

Mentalizing, a multidimensional concept rooted in attachment theory and the psychoanalytical work of Peter Fonagy, OBE, PhD, Chief Executive of the Anna Freud National Centre for Children and Families in London, United Kingdom, may offer some insights into understanding life online. Briefly, mentalizing involves the perception and interpretation of behavior based on intentional mental activity, an imaginative capacity that determines how we relate to others as well as ourselves.15-16

According to Dr Fonagy, poor mentalizers often focus on the surface and lack curiosity. They cannot conceptualize the thoughts, feelings, and desires that underpin another persons communication. In social interactions, they may take something seriously that others would discard or perceive as a mild joke. Social media offers considerable opportunities for misunderstanding and a lack of insight into others motivations and true meanings.

On the whole, with any media including social media, if you are a vulnerable individual, you are much more likely to be negatively affected by it, Dr Fonagy stated in a Zoom call. If you have mental health problems before using it, you will suffer from it. If you have no mental health problems, it may affect you less.

Joint attention and epistemic trust lie at the heart of Dr Fonagys notion of mentalizing. Social media often provides highly individualized content that fractures users collective experiences, and online platforms draw users attention in unique ways.

Dr Fonagy noted that skilled teachers can develop epistemic trust, and social media masquerades as if it is a teacher that recognizes you; that recognition of individual agency opens your mind, allowing you to be influenced. This phenomenon leads to an abuse of epistemic trust, and adolescents are particularly vulnerable to social influences, according to Dr Fonagy.

These concepts not only allow for an understanding of online life on a larger level, but also for successful interventions in clinical settings. Adolescents psychological challenges are increasingly entangled with their experiences online and virtual interactions with their peers on social media. As a result, providers need to take into account the unique aspects of these interactions and online adolescent culture.

I see a lot of people who have problems associated with social media, Dr Fonagy stated. People that I see are massively bothered at the extreme by cyberbullying. And,at the minor level, by not getting enough likes.

To alleviate these problems, Dr Fonagy deploys a mentalizing approach to develop better epistemic trust and discernment, which can involve stopping automatic thinking and getting a more reflective stance, a balance of cognition and emotion. For adolescents concerned about a lack of likes or a friend not responding to their messages, a mentalizing approach can help them think about what motivates other people. Could the friend be busy doing something else and still care about the relationship? Should I determine my self-worth based on likes? Why do I jump to conclusions about not getting positive attention?

An important starting point involves validating adolescents perspectives, even if they are flawed, to develop clinician-patient trust. For example, a provider can validate that interactions online can be upsetting in a sincere way and that peers may be acting in an unfair manner. Then, by clarifying and getting into the details, Dr Fonagy said, You gradually help them recover a more sophisticated mentalizing stance.

Immediately offering a contrary perspective can result in adolescents pushing back and building up a barrier. However, as Dr Fonagy stated, Once they feel comfortable that you can see the world how they see it, then you can take a different perspective on board. Then, clinicians can demonstrate that anxieties or judgments about others behavior may be a projection of the patients insecurities and assumptions.

Conclusion

Providers should be aware of the multitude of stressors that their adolescent patients are currently facing as a result of the COVID-19 pandemic, and social media may play a relatively minor role overall. Given the literature linking problematic social media use to suicidal behavior, self-harm, psychological distress, and psychiatric disorders, providers should also pay attention to potential warning signs.17-19 However, they ought to consider that their adolescent patients are equally cognizant and concerned about these problems.12

Moving forward, developing a culture of healthy social media use requires more than self-awareness on the part of adolescents or restrictions by watchful parents. Harrison believes that much more focus needs to be placed on minimizing harm on platforms and it should not be left up to users or the conscience of platforms to figure this out and manage it. She added, As a society, we need to demand that positive impacts on mental health and wellbeing be a driving force behind design and growth within the technology sector.

Participating in this wider social conversation, however, should not play into technology panics or reactive fears.10-11 Problems experienced online are often experienced offline as well, and the impacts of technology are not equally distributed, with some adolescents being more affected than others.10,20 To explore the multifaceted relationship between social media and adolescent mental health, researchers should design better studies that move beyond mere correlations and analyze how technologies are actually experienced.

References

1. Fischer S. Social media use spikes during pandemic. Axios. https://www.axios.com/social-media-overuse-spikes-in-coronavirus-pandemic-764b384d-a0ee-4787-bd19-7e7297f6d6ec.html. Published online April 24, 2020. Accessed November 16, 2020.

2. Ghaffary S. The pandemic is raising concerns about how teens use technology. But theres still a lot we dont know Vox Recode. https://www.vox.com/recode/2020/7/29/21346005/technology-social-media-impact-teenagers-research-common-sense-report. Published online July 29, 2020. Accessed November 16, 2020.

3. Centers for Disease Control. Coping with stress. CDC Coronavirus Disease 2019 (COVID-19) Your Health. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html. Last updated July 1, 2020. Accessed November 16, 2020.

4. Zhong B, Huang Y, Liu G. Mental health toll from the coronavirus: social media usage reveals Wuhan residents depression and secondary trauma in the COVID-19 outbreak [published online August 15, 2020]. Comput Human Behav. doi: 10.1016/j.chb.2020.106524

5. Gao J, Zheng P, Jia Y, et al. Mental health problems and social media exposure during COVID-19 outbreak (published online April 16, 2020). PLoS One. 2020;15(4):e0231924.

6. Saha K, Torous J, Caine ED, Choudhury MD. Social media reveals psychosocial effects of the COVID-19 pandemic [published online August 11, 2020]. medRxiv. doi: 10.1101/2020.08.07.20170548

7. Panchal N, Kamal R, Orgera K, et al. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. Published online August 21, 2020. Accessed November 16, 2020.

8. Orben A, Tomova L, Blakemore SJ. The effects of social deprivation on adolescent development and mental health. Lancet Child Adolesc Health. 2020;4:634-40.

9. Orben A, Przybylski AK. The association between adolescent well-being and digital technology use [published online January 14, 2019]. Nature Human Behavior. doi: 10.1038/s41562-018-0506-1

10. Odgers C. Smartphones are bad for some teens, not all [published online February 21, 2018]. Nature. doi: 10.1038/d41586-018-02109-8

11. Orben A. The Sisyphean cycle of technology panics. Perspectives on Psychological Science. 2020;15(5):1143-1157.

12. OReilly M, Dogra N, Whiteman N, Hughes J, Eruyar S, Reilly P. Is social media bad for mental health and wellbeing? Exploring the perspectives of adolescents. Clin Child Psychol Psychiatry. 2018;23(4):601-613.

13. Barry CT, Sidoti CL, Briggs SM, Reiter SR, Lindsey RA. Adolescent social media use and mental health from adolescent and parent perspectives. J Adolesc. 2017;61:1-11.

14. Cavazos-Rehg PA, Krauss MJ, Sowles S, et al. A content analysis of depression-related tweets. Comput Human Behav. 2016;54:351-357.

15. Bateman AW, Fonagy, P. In: Handbook of Mentalizing in Mental Health Practice. 2nd ed. Washington, DC: American Psychiatric Association Publishing; 2019.

16. Fonagy P, Luyten P, Allison E, Campbell C. Mentalizing, epistemic trust and the phenomenology of psychotherapy. Psychopathol. 2019;52(2):94-103.

17. Marchant A, Hawton K, Stewart A, et al. A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown [published online August 16, 2017]. PLoS One. doi: 10.1371/journal.pone.0181722

18. Marino C, Gianluca G, Vieno A, Spada MM. The associations between problematic Facebook use, psychological distress and well-being among adolescents and young adults: A systematic review and meta-analysis [published online January 15, 2018]. J Affect Disord. 2018;226:274-281

19. Andreassen CS, Billieux J, Griffiths MD, et al. The relationship between addictive use of social media and video games and symptoms of psychiatric disorders: A large scale cross sectional study. Psychol Addict Behav. 2016;30(2):252-62.

20. George MJ, Odgers CL. Seven fears and the science of how mobile technologies may be influencing adolescents in the digital age. Perspectives on Psychological Science. 2015;10(6):832-851. doi: 10.1177/1745691615596788

Original post:
Living Life Online: Adolescent Mental Health and Social Media - Psychiatry Advisor