Engaging Mental Health Online: Insights from beyondblue's Forum Influencers (2018, New Media & Society)

Engaging Mental Health Online: Insights from beyondblue’s Forum Influencers Anthony McCosker, Swinburne University of Technology, Melbourne Citation: McCosker, A. (2018) ‘Engaging Mental Health Online: Insights from beyondblue’s Forum Influencers’, New Media and Society, online first: https://doiorg.ezproxy.lib.swin.edu.au/10.1177/146144481 Digital platforms offer an important means for improving the reach, scale and accessibility of community-based support for those dealing with mental health issues. They enable new forms of health participation. A research gap remains in understanding the role of peer mentors in building effective digital environments for mental health support. This paper presents part of a larger study centred on the digital interventions of prominent mental health organisation beyondblue. It combines qualitative content analysis and interviews with prominent peer mentors. The analysis presents insights into how some peer mentors are able to act as mental health influencers and examines their impact and role in activating supportive mental health publics. Effective mental health influencers build demonstrable non-professional expertise and authority, and through affective practices play an active role in framing and re-framing mental health and recovery, stimulating cohesion generating cycles of impact-feedback among forum participants. Keywords: mental health, online forums, expertise, peer mentors, influencers, affect, moderation Introduction In 2014, the Australian Report of the National Review of Mental Health Programmes and Services emphasised the ongoing importance of online forums among other digital media tools for offering peer support and addressing mental health issues ‘in the community’. Recommendation 11 stressed the need to: ‘Promote easy access to selfhelp options to help people, their families and communities to support themselves and each other’ (National Mental Health Commission, 2014, Vol 1: 87). Likewise, the National Institute for Mental Health in the UK points to the way digital technology ‘has opened a new frontier in mental health support and data collection’ in its effort to promote research exploring new technology-based interventions for mental health support (National Institute of Mental Health, 2017). Similar proclamations in the US follow decades of advocacy from patients and health organisations alike for the need to address mental health issues through community-based and peer-run programs (Clay, 2005). 1 Over the last decade, social media platforms have reconfigured communication beyond geographical boundaries, and hence seem to offer a potential solution to addressing public health issues at scale and through peer-led interventions. As Kivitz notes, the internet and social media have ‘made new experiences of health and illness possible’ (Kivitz, 2013: 223). But with the diversification of the ‘e-mental health ecosystem’ spanning promotion, treatment, recovery and prevention (Burns et al., 2016: 589), mental health organisations have to make choices about how to allocate limited funding to support services, raising questions about which digital tools to invest in, and how effective they might actually be. Digital platforms not only provide an avenue for health information access and sharing, they actively alter the ‘public-professional relationship’ (Kivitz, 2013: 220-221) or the ‘expert-client relationship’ (Mowlabocus et al., 2015), and introduce the potential for peer-led support practices (Tanis, 2008). In fact, across high and low-income countries, many health organisations see peer networks and health influencers as crucial for effective digital interventions (Castañeda et al., 2010; Campbell et al., 2007). A research gap remains in understanding the role of peer mentors in building effective digital contexts for mental health support, and particularly the work of the variously named community champions, intermediaries or health influencers that drive and modulate interaction and support often outside of health organisations’ communication, outreach and health campaign efforts. This paper presents part of a larger study of online mental health support centred on the digital interventions of prominent Australian mental health organisation beyondblue (McCosker, 2017; McCosker & Hartup, 2018). In this paper I draw on qualitative content analysis and interviews with prominent peer mentors to explore experiences and activities within beyondblue’s online forums. The forums offer a site in which to examine the broader potential of peer mentors as health influencers in the context of organised online mental health support. How do peer mentors and moderators act as change agents in this context? What forms of influence and impact do they achieve? What is the value and productive capacity of their affective labour to bring into being and sustain supportive mental health communities? The analytical framework developed and applied draws from a growing body of work addressing peer mentors and health influencers, along with approaches to intermediation and moderation practices. The analysis presents insights into how some peer mentors act as mental health influencers in online, and the platform features that contribute to a supportive environment for vulnerable publics. It details the generative qualities of the aversive affects (McCosker, 2013) associated with mental ill health and the empathy practices that underpin the expertise of mental health influencers. In this context, effective health influencers build demonstrable non-professional expertise and authority, play an active role in framing and re-framing mental health and recovery practices, and stimulate cohesion-generating cycles of impact and feedback among forum participants. 2 Online mental health support: Intermediaries and health influencers There is strong evidence of the benefits of community-based health, social support and peer networks in aiding the ongoing recovery aspects of mental ill-health in combination with clinical or acute care (Campbell, 2005; Moorehead et al., 2013). When isolating the range of health benefits associated with digital technologies, empowerment is often emphasised, with some also focusing on how health empowerment plays out in practice or in specific online contexts, and the emotional and affective labour that accompanies health participation (McCosker & Darcy, 2013; Tucker & Goodings, 2017; Stage, 2017). Hardt and Negri (2004: 108) defined the concept of affective labour as ‘the labour that produces or manipulates affects such as a feeling of ease, well-being, satisfaction, excitement, or passion’. This resonates with Hochschild’s (2003) accounts of the blurred lines between caring or health service work and ‘feeling management’. These factors should be taken into account when considering the benefits of digital platforms, which have been understood to increase information access and sharing, strengthen self-reflexive, self-directed health practice, and increase opportunities for finding supportive relationships beyond geographical or immediate social networks (Moorehead et al., 2013). Like all spheres of digitally mediated social life, health participation is uneven. Digital technologies such as online forums, mobile apps, and social media platforms do not automatically solve the issues of social inclusion and exclusion that affect those living with mental health problems (Boardman et al., 2010), and may in some cases exacerbate them (e.g., Royal Society for Public Health, 2017). However, one point of focus is the role that peer mentors can play in engaging the ‘hardly reached’ (Sokol & Fisher, 2016) in health outreach and support. Davidson et al. point out that while peer support is generally attributed to the mental health service user movement in the 1970s, it can be traced back at least to the writings of Jean Baptiste Pussin in the late 18th Century, along with practices of hiring recovered patients to staff psychiatric inpatient units in the US in the 1920s (2012: 123). Significant benefits have been identified in peer support programs, where positive self-disclosure builds hope regarding control over debilitating conditions and symptoms; role modelling introduces strategies for selfcare and recovery through embodied, experiential knowledge; and peer provider and recipient relationships develop trust, exhibit empathy and conditional regard, and hence better address conditions through professional services (Davidson et al., 2012; Clay, 2005). There is growing interest in the ways health organisations might benefit from peer mentors and health influencers. This includes the widespread use of ‘community health workers’, especially in development health programs in the global south (e.g., Choi et al., 2016); ‘champions’ in programs such as chronic disease risk reduction (Aoun et al., 2013), or ‘community health champions’ and ‘lay public health workers’ supported in the UK (Woodall et al., 2013); and ‘health influencers’ in tobacco control (Castañeda et al., 2010; Campbell et al., 2007). ‘Patient navigators’ have played a 3 similar role in stewarding marginalised people through complicated health systems and institutional practices (Natale-Pereira, 2011). ‘Brokers’, ‘boundary spanners’ or ‘bridges’ are understood, often in relation to network theory (Barabási, 2003), to facilitate transactions and information flow or enroll marginalised people into health programs and services and are crucial for building collaborative networks in health care contexts where isolation, silos, marginalisation and other forms of social and health exclusion occur (Long et al., 2013). In health outreach and promotion, the intermediary role of digital platforms combines with the ‘digital expertise’ of outreach workers (Mowlabocus et al., 2015). Social capital and expertise are crucial to these roles and encompass a level of health knowledge, but also the ability to navigate the perils of the publicness of online support (Mowlabocus et al., 2015). In the case of online mental health support, connectors, intermediaries or influencers designate those who act with a degree of vernacular authority to bridge professional and non-professional divides, establish and sustain supportive online communities and help to frame and re-frame others’ experiences of mental ill-health. Identifying expertise, qualifying influence The analytical approach developed in this paper targets the embodied expertise and influence of peer mentorship. While the ‘public-professional’ dichotomy has been instrumental in health practices and power dynamics, there has been a ‘destabilisation of expertise in the modern era’, particularly through the impact of digital platforms and peer networks (Kivitz, 2013: 221). There is debate about the politics and power dynamics in essentialising forms of lived experience (e.g. Voronka, 2016); however, lived experience challenges notions of expertise, whether health, biomedical or cultural, inspiring attempts to mobilise new forms of community-oriented and personalised public health intervention through digitally mediated peer practices. Questions of risk associated with support provided by non-medically trained intermediaries do persist (Hendry et al., 2017), as expertise in this context involves a complex mix of trust, authority and authenticity related to peer and social influence, rather than health training. Forum members, for instance, apply a range of techniques to assess credibility, and are particularly drawn to experiential information (Lederman et al., 2014). Moreover, trust in ‘official’ sources of health communication can be diminished and inverted by emergent social media norms, where peers provide greater access and cutthrough than other sources of ‘official’ health information (Albury et al., 2015; Byron, 2015). The distinction I am drawing here between peer mentors and health influencer is subtle. Both might offer social support in relation to their embodied experience, potentially in an ‘official’ role as a Champion, for instance. However, the elements of influence, authority and developed expertise offer a key point of distinction and are the 4 target of this paper. The peer mentors and health influencers I refer to in this research do not have a direct role in content moderation, which is the domain of content filters and beyondblue’s community manager, but rather in interaction modulation, shaping conversations and framing practices in the forums. The concept of health influencer adopted here builds on the research surrounding peer mentors in public health communication and outreach, but also shares some characteristics of the fame and commercially oriented ‘ordinary celebrities’ (Turner, 2010) of contemporary media cultures, or ‘microcelebrities’ of Instagram, YouTube or Twitter (Senft, 2012; Abidin, 2016; Mavroudis & Milne, 2016). In these studies, ‘influencer’ describes social media actors who have developed a niche but prominent level of notice and a large follower or friend base while sharing their everyday lives across a range of platforms (Abidin, 2016). For Senft (2008, 2012) this involves the use of mediated self-presentation to project a coherent branded identity maintained as if an artist or entrepreneur (see also Marwick, 2013). Influencer practices address the potential of social media for generating peer-led forms of social participation in contexts that shift some emphasis toward participatory acts capable of mobilising populations outside of traditional communication channels. Health influencers have been shown to effectively mobilise informal communication networks even where they lack core health knowledge (Castañeda et al., 2010). Expertise is of a different kind to the knowledge-based training of health and medical professionals. Health influencers intermediate, legitimate positive health frames and are able to build effective communities of practice through skilled interpersonal action, and this is enhanced when training is available (Castañeda et al., 2010). The framework I apply emphasises the establishment of embodied expertise and targets the strategies and devices that generate observable types of influence. Other important analytical approaches could be taken here to account for the activities and experiences of the forums focusing, for example, on cultural legitimacy and capital in Bourdieu’s sense, the competing knowledge systems and discourse production processes, or a more targeted focus on affective, emotional and immaterial labour (e.g. Tucker & Goodings, 2017; McCosker & Darcy, 2013). I examine expertise and influencer practices here as a pragmatic approach to understanding and applying the insights of those who drive and sustain engagement in the forums. Cultural intermediary theory and research offers some specific and useful reference points (Smith Maguire & Matthews, 2012; Hutchinson, 2017); however, this research tradition is primarily concerned with the contextual and mediating factors in markets and the link between production and consumption (McFall, 2014). I draw from this approach Smith Maguire and Matthews’s (2012) key elements of cultural intermediary to examine a) expertise, b) framing and c) influence. Like other social media contexts in which community, sociality or publics are dynamically formed and mediated by socio-technical and affective factors (McCosker, 2015), there is an unevenness to participation characterised by the prominence and influence of certain actors, and the intimacy, affect, intensity and 5 transience of acts of participation. The aim is to characterise the participants and the pathway from expertise to influence to enhance their effects. Methods and data collection One of the challenges of studying any online forum or community platform is identifying and accessing the practices, motivations and perceptions of the key influential participants, particularly in relation to sensitive social and health issues, and where pseudonymity is mandated. This study applied digital ethnographic observation of activity across beyondblue’s online support sites over several years. The starting point was to identify and gain access to key informants and prominent, influential forum participants, and then observe practices, events and activities in the forums over time. The approach draws from social media ethnography (Postill & Pink, 2012), applying a sensitivity to practices – what people do with and on social media – and the features of the platforms that also act to shape and influence sociality, enabling the dynamic, and often contested formation of vulnerable publics (McCosker & Wilken, 2017). The methods combine interviews with peer mentors and key informants with a quantitative and qualitative content analysis of a sample of forum data (5 forums, 14 threads, 1140 posts). Ten Community Champions were recruited by invitation via the private Champions forum, a process facilitated by beyondblue’s community manager. In-depth interviews focused on how Champions understand and undertake their role in the forums, and the challenges and benefits of engaging with mental health issues online. Interviews were conducted by phone due to the geographical distribution of participants, between February and April 2017. Thematic analysis involved both inductive and deductive processes, guided by a priori categories related to the analytical framework discussed above. The Champions involved in the interviews are identified by their pseudonymous forum usernames by their own preference, and in accordance with the ethical consent obtained: White Rose, Kazzl, Wednesday, white knight, Just Sara, Starwolf, geoff, MarkJT, Croix, Gruffudd. Other non-champion participants quoted have been attributed an alternative pseudonym, or double deidentified. beyondblue does not collect personal information or display any information for a forum user other than a pseudonym. The Association of Internet Researchers Ethical processes were considered throughout. While posts are publicly accessible through the forum, sensitivity to the context and purpose of posting to the forum has been weighed when relocating those posts to this research paper. As well as double deidentification, the posts reproduced have been chosen as representations of the kinds of activities and patterns observed and have minimal reference to specific circumstances or experience. The forums are publicly accessible by organisational policy because they also stand as a resource for others to read, follow, and learn from, and this is made clear to participants in the terms of use. Any possible harm in reproducing them in this research is also weighed against those objectives. Communication with beyondblue’s community manager regarding process and ethical oversite was constant, beginning with research 6 design, formal ethical review, and through sign-off for any publications. The findings have helped inform training workshops for Community Champions at the organisation. Observations of the forums took place between 2015 and 2018, with a sample of forum interactions extracted in December 2016. The selection is broadly representative of forum activity, with three people-oriented forums that focus on the Champions, young people, and partners and carers, along with two illness-focused forums. The forums were: ‘Welcome & orientation’ (1 thread, 120 posts), ‘Depression’ (4 threads, 390 posts), ‘Anxiety’ (4 threads, 360 posts), ‘Young people’ (1 thread, 60 posts), ‘Supporting family and friends (carers)’ (4 threads, 210 posts). Analysis of the forums occurred in two phases. An initial phase helped identify key influencers and explored broad patterns of interactions and content themes. A second phase occurred after interviews with Champions, where a coding frame was established to identify the characteristics, practices and expressed impact of the forums’ influencers. This coding frame was developed through a mix of inductive and deductive processes, and was tested for consistency between two researchers, with sub codes adjusted through an iterative process. Moderated forums and distributed support: Enabling ordinary influencers It is not surprising that online forums have emerged and remain a persistent, organic source of community support from the early days of the internet. Forums have operated in this capacity alongside bulletin boards, email lists and other tools for issue- or interest-oriented sharing and interaction, well before current social media platforms (Baym, 2015). In fact, notions of online community and participatory practices have predominantly been understood with reference to forums, and they share continuity with prominent ‘community forums’ like Reddit, to use Massanari’s term (2015). Forums offer a shared sense of space, practices, resources and support (emotional, esteem, information support), along with shared identities and interpersonal relationships (Baym, 2015: 82-100). Health forums have been found to facilitate participation and inclusion in health and wellbeing processes and information gathering, expand personal networks, offer anonymity for stigmatised and vulnerable populations, increase access to support mechanisms particularly for those isolated or of restricted mobility (Tanis 2008). Tucker and Goodings detail the ‘digital atmosphere’ generated by the transmission of affects on forums like the UK-based mental health forum Elefriends, but also the way ‘caring for oneself becomes bound up in the ambiguities of caring for others’ (2017: 629). These findings resonate strongly with the beyondblue forums. A growing number of around 88,000 people access beyondblue’s mental health support forums monthly (McCosker, 2017). The forums have been in operation since 2003 and are currently managed by two paid moderators and around 20 unpaid ‘Community Champions’. beyondblue developed its Champions program in a relatively ad hoc way, initially drawing from a small number of prominent forum influencers already active – those who posted often and were well known to help and support 7 others. All Champions have lived experience of mental ill health, as well as demonstrated prominence overtime (digital expertise). They receive some training through workshops run annually and also have access to a dedicated closed forum where they can seek advice, information or strategies from the other Champions, or interact with beyondblue’s community manager. Champions also have access to one-onone clinical debriefing if they are distressed by any interaction on the forum. An automated, three-tiered filtering system assesses posts for levels of risk on the basis of flagging protocols, with about 20% of higher risk posts held back for review. The moderation protocol flags posts that among other criteria promote services or particular pharmaceuticals, are aggressive, or talk about suicidality with specific reference to time and place or methods. Users cannot themselves flag posts in the current iteration of the forum; although Champions can and do direct concerns to the community manager. Along with the community manager, clinically trained moderators can step in where a high risk is identified. On the rare instance where an emergency situation is identified, local authorities can be directed to a location derived from the IP address of the forum member. Posts are limited to text, 2500 characters long, and are publicly accessible through search engines; however, membership through a sign-on process is required in order to post or reply, and membership is restricted to people located in Australia by IP address. Survey work undertaken in 2016 found most members accessed the forums because they ‘felt depressed or anxious and I wanted support’ (55%), ‘wanted to connect with others anonymously’ (33%), or ‘felt suicidal’ (26%) (Hall & Partners Open Mind, 2016: 13), the latter being higher for 18-24-year-olds (36%) who post at much higher rates to the ‘Suicidal Thoughts and Self-Harm’ forum (McCosker & Hartup, 2018). Notably, a substantial number (18%) explicitly ‘wanted to provide help’ to others. A range of factors contribute to enabling engagement with the forums but central would be the requirement for anonymity. Unlike platforms with a real name premise (van der Nagel & Frith, 2015), the forums require pseudonyms to encourage intimate self-disclosure without the social and identity risks associated with mental illhealth’s persistent stigma. Interview participants uniformly saw this as essential. For Starwolf, anonymity ‘is actually a necessity. That’s what allows people to open up’. For Gruffudd, ‘it’s important for trust and confidence… When people find the forums, life isn’t great. They have relatives or employers giving them a pretty hard time. And they are a little bit worried about that conversation being shared with those people’. Establishing expertise In any social context there is commonly an ‘asymmetry of influence’ (Smith Maguire & Matthews, 2012), and this holds true for forums generally (Baym, 2015). For digital environments, the important question is how expertise is established, or how some individuals become distinguished through implicit and explicit claims to privileged experiences and through legitimising techniques and affective, influential digital acts. 8 Factors contributing to this asymmetry of influence might include experiential knowledge (including cultural or vernacular knowledge), duration of participation, social capital or network size and visibility, acknowledged skills, capacities or proximity to service providers. Legitimacy, authority and expertise are characterised in online forums by demonstrable skill and the sustained application of affective labour in managing micropublic conversations about sensitive and context-specific issues. beyondblue’s forums foster a particular kind of asymmetrical influence among members most explicitly through markers of expertise and experience indicated by a profile badge (Community Champion, Valued Contributor, blueVoices Member), and visible number of posts. While some noted that badges have been contentious at times, they emphasised that they are almost always ‘deserved’ and saw the important role they play in conveying a sense of ‘reward’ for effort and involvement over time, ‘recognition’, ‘validation’, ‘acknowledgement’, and in signaling the esteem associated with Champion roles. Badges in this sense can be understood as ‘professionalising devices’, a contingent accomplishment attributed by beyondblue moderators but also legitimised by forum members through cycles of feedback and acknowledgement of the impact that Champions have for others at times of need. For Gruffudd, ‘It’s why it’s quite nice to be a rainbow champion, have a brightly coloured bus that’s a little bit different.’ This has a double effect of signaling a safe environment for new LGBTI members, and a specific kind of support-expertise: ‘if someone from an LGBTI background is coming into the forums, there’s someone else there that’s identifiable without having to ask. And then it’s okay and it’s clearly a safe place because that conversation is already there’ (Gruffudd). In the forum analysis and interviews with Champions, a number of themes and practices emerged that gave insight into how expertise was established. Over a long period, those who achieved the status of Valued Contributor or Champion relay in intimate detail personal mental health and life circumstances often involving times of severe mental ill-health and transitions toward successful coping and recovery practices. Just Sara describes this last quality of transition, and its non-linear characteristics: when you first become a CC, there’s a transition that has to happen, and it’s going from a ‘needy’ Member to a Member with accountability and responsibility. And you sort of lose yourself a bit in that transition, because all your time is spent helping others, and you’re still going through your own stuff. You just can’t lose your own needs. (Just Sara) This involves a kind of managed or performed intimacy through which peer influencers are able to connect on an intimate level while retaining some distance. Just Sara goes on to explain this: personal experience is very important. I usually gauge whether or not to tell a little bit about myself. I used to, in the beginning, tell a lot about myself, and then I thought no, there’s too much redirecting there, so I usually just put a few 9 statements about my experience if I need to. (Just Sara) The ‘Introducing’ thread repeatedly pairs personal mental health issues and difficult life experiences with coping and recovery strategies as credentialing practice or indicators of expertise. In one post Lori says: ‘I am 18 years of age … I have experience with depression and anxiety myself and if there’s ever a time when I can help another I will…’ (Lori7, Forum: Welcome & Orientation). Age, depression and anxiety feature upfront here as the identifiers of supportive capacity. In some cases, a professional credential is put forward, such as role as nurse, psychology student. Just Sara noted that: It basically has replaced my career. I’ve always been in the helping professions … Becoming a Champ, although it was quite confusing in the beginning because I went through a lot of emotional stuff, it has become my work, and very, very important to me. (Just Sara) Embodied personal experience is central to how forum influencers operate, as Croix notes in interview: ‘If it’s talking about being hospitalised, fine. If it’s talking about being suicidal, fine. …Whereas some things are so alien that I really feel that it’s a last resort for me to [respond]’. For Kazzl personal experience establishes authority and relatability: ‘I think it’s, what’s the word I’m looking for, credibility in what we say to people, because by sharing our own experiences they can see the credibility in what we’re saying’. But embodied experience is not in itself enough to distinguish key influencers. Champions and other influencers demonstrate an ability to draw on and express personal mental health experiences in a way that builds trust, encourages communication and nurtures relationships among forum members to counteract the negative social norms around mental ill-health. A significant part of the authority achieved by influencers derives from their capacity to transform the aversive affects of their own encounters with mental illness into a mechanism for connecting – or connecting with – others. Kazzl sees the role as both ‘validating people’s experience’ and challenging the persistent idea ‘that it’s a character flaw, it’s a weakness’ (Kazzl). This validation becomes reciprocal over time, through cycles of feedback and forms the basis of a durable portfolio of authority and expertise. Framing and re-framing mental health: Durability, credibility and empathy A second element of focus is the role that forum influencers play in framing practices, which refers to both the act of expertly articulating mental health experiences and recovery strategies, and the durable frames, points of reference, key posts, ideas, practices and behaviours that hold sway or take shape as norms or conventions – particularly through the interpersonal flow of affects and the generation and management of empathy. Individuals who achieve a level expertise and influence do so in large part by effectively framing and reframing ideas, ways of thinking and 10 behaviours; and likewise, because they have established expertise and authority they are better able to make choices and strategies credible to others. In this way they are implicated in providing legitimacy to practices, or even generating conventions (Smith Maguire & Matthews, 2012: 557). Framing and empathy practices function as primary affective techniques, providing a basis for facilitating ‘the “sociality” of emotion’, as Ahmed puts it (2014: 8) that sustains engagement within the forums. The forum analysis and interviews revealed Champions’ active role in providing articulate, evocative, experience-oriented accounts of the symptoms and affects related to mental health problems in ways that other members respond to. Blondguy is known for his evocative language and ability to articulate the qualities of mental illness. In one thread, in response to an ongoing discussion about how to support an unwell partner, he explains: ‘Depression can close in on us like a fog. It dulls or removes senses, short circuits emotions, makes thoughts all warpy and steals energy’ (Blondguy, Forum: Depression). Some draw attention regularly to the chemical and biophysical aspects and effects of mental illness as a way of shifting frames of reference away from interpersonal problems or expressions of low self-worth: ‘It feels that way because the chemistry in your head is a bit out of kilter at the moment, it won’t be forever’ (Wednesday, Forum: Depression). Alternative non-medical framing of the effects of anxiety also helps, for example, to explain behaviour patterns and reflect on recovery strategies: ‘Anxiety is the pits. The mouse on the wheel around and around and around is the anxiety’ – a metaphor Corn returns to on other occasions, and others respond positively to (Corn, Forum: Anxiety). In framing recovery practices for others, Champions repeatedly refer to strategies developed from a mix of their own practiced approaches. This is exemplified by the regular reference to mindfulness or techniques like cognitive behavioural therapy (CBT). Champion Mark JT offers a fairly prescriptive example of techniques that work for him: ‘Do you practise mindfulness? If not, start. It is awesome and one of three key subjects that i do daily to keep and continue to build my resilience’ (Mark JT, Forum: Depression). Some posts and ideas achieve durability despite the relative transience of posts as new content emerges. For example, framing her top recovery strategies, White Rose offers a list that is both personal and generally applicable; the top 4 on her list are: 1. Sit outside and watch/admire my garden. 2. Meditate. I can also do this outside once general peace of the garden has settled me. 3. Phone a friend. No guarantee someone will be available so I tell myself I can talk later. 4. I like craft work, especially if it needs a lot of attention. This stops me focusing on my misery. (White Rose, Forum: Depression) 11 White Rose and others refer back to this post or versions of it regularly, and each of the elements remain central to her approach to helping others address their own circumstances. Such a post stands as a point of reference or convention, against which the legitimacy of personal recovery approaches is oriented and understood or negotiated by others. Members refer back to White Rose’s list as an already substantiated version of a point they are making: Hi Mary [White Rose]. Thank you so much. I love the way you explained everything and it all makes sense to me. […] I Can relate to your strategies and will definitely try them. I Will revisit your post when i am feeling lonely next time so thank you. (Penny, Forum: Depression) White Rose (who also goes by another alias, Mary), clearly understands the durability of some posts, as this reply to her advice regarding a psychologist’s appointment suggests: ‘Mary that’s not a bad idea about printing out my original post and taking it with me ... would she read it? I could read it out to her perhaps.’ (Moonshadow, Forum: Depression). The relative stability and archival form of the forums, the visibility of threads overtime, but also these deliberate techniques in fixing affective reference points in posts, establish a base for rendering frames, strategies and interactions durable, and represent the primary digital labour and expertise of peer influencers. Forum influencers are particularly skilled at re-orienting others’ negative experiences and helping other members to think more positively and strategically in redressing their particular circumstances and problems through techniques of empathy. These techniques involve the management or modulation of the negative affects and emotions associated with critical moments of mental ill health. In interviews, Champions Kazzl and Geoff explain how they go about this: [I] ask them to think back to before they became so depressed and what kinds of things they enjoyed doing, because it’s something that we can forget, that life can be actually pleasurable; and then just say to them what do you like to do and take it from there. (Kazzl) [I try] to put myself into their situation. Make them understand that I’ve been through it as well and come out the other end. It’s always negative thoughts, and I can well and truly understand that. Just trying to relay to them that what they’re going through is terrible, but then I try and think back to what I went through, then mention what I’ve been through, not as me saying it, but what they could do instead. (Geoff) In these instances, and in each of the interviews, Champions relay the importance of empathy practices. They talk about empathy as a vital attribute and competency, a tool for maintaining connections with other members long enough to understand and reframe problems. As Starwolf explains: ‘this is what gives people, gradually sometimes, 12 the incentive to open up a little bit more. Feeling that they are not judged, they’re understood and somebody cares. It’s just a matter of building up a trust relationship’ (Starwolf). Not only do techniques of empathy in interactions facilitate connections and relationships overtime, they are generative of developed expertise and authority. For Kazzl this involves two stages: using empathy to ‘reflect back to them what they’re experiencing’, and then drawing them out: ‘I don’t think you can ever really resolve something that’s going on in one post, so I always try and get them to tell me more, draw them out, though not “please can you tell me everything”’ (Kazzl). What became clear through the interviews, and observing empathy practices in the forums, is that influencers excel at generating and mobilising empathy as a form of skillful affective labour, the result of which is to bring into being and sustain supportive mental health communities. This is facilitated by recurring cycles of feedback-impact. Cycles of feedback: Levers of influence The impact of forum interactions and drivers of influence are always uncertain but involve observable cycles of feedback. The work of influencers in these cycles is to structure ongoing modes of engagement, develop and manage relationships and strengthen community norms or conventions. These practices ultimately shape conversations as a kind of community-driven ‘public mental health pedagogy’ (Fullagar et al., 2017). The cycles of impact-feedback resonate with work on affective economies, where the sentiment, or the feeling of affirmation (in a context of aversive emotional and affective states and experiences) attains an autonomy and circulates (Massumi, 2002), but also constitutes the sociality of emotion (Ahmed, 2014), its publicness and its public modulation. That is, expressions of feedback circulate an affective, relational force that sustains the ‘feeling’ of community. Smith Maguire and Matthews note that a central aim of cultural intermediaries is to ‘make their impact durable…such that it extends beyond their particular interactions and accomplishments and takes on the quality of a convention’ (2012: 557). The various signs of impact observable in the forums offer a clue as to how this happens in practice. I categorise the impact signaled and exchanged through feedback as acknowledgement and recognition, agreement, and actioning. These forms of exchange carry an important visibility or publicness and take a cyclical and durable form. Acknowledgement and recognition of others’ input or specific comments is the most common form of impact-feedback. It expresses a fundamental appreciation and maintains a connection. It may be relayed in an expression of thanks – generally or targeting an individual: ‘Thank you so much for your post and your generous words. The BB forum has kept me going so it works both ways’ (Wednesday, Forum: Depression). Or it may involve ‘calling out’ others: ‘Hi Wednesday Thanks big time for replying :-) James, Bluguru and Carol are legends on the forums that I have learnt a lot from since they been “on the air” It really makes me feel mega grateful that they are 13 here’ (blondguy, Forum: Depression). That recognition might signal the impact of the forum community as a whole: ‘Thank you, it means a lot, even to have support from a stranger xx’ (Rach1, Forum: Young People). Agreement takes the signal of impact further than recognition or expressions of appreciation. These are buttressing statements: ‘You’re right sometimes it is just having someone to listen that helps’ (Wednesday, Forum: Depression). They also help to acknowledge and maintain contact and supportive relations, but can gesture toward a reinforcement or even shift of thinking, with the possibility of more positive action: ‘Geoff and Mary - I will try to not hang onto any self-control seeing the psych. I don’t put on a facade deliberately believe me - I don’t think I could tomorrow anyway’ (Moonshadow, Forum: Depression). When cycles of feedback move toward specific enacted responses, or actioning, influence becomes explicit and visible to others. Actioning signals impact and influence in a way that indicates not only agreement and appreciation, but material change. As one of many examples of actioning, Shephard relays his attempts to overcome negative thoughts and follow the advice of a non-Champion forum influencer Sun: Even though i feel emotional i am doing what you suggested [Sun] and just letting go of my negative thoughts, most of the negative thoughts i have are generally not based on reality and are useless but I seem to fall for them way to many times. (Shephard, Forum: Depression) Impact is not always made visible for Champions and forum influencers (to their frustration), but when it is it affects motivations, interaction and support strategies. Influence is multi-directional in this sense, and cyclical. Its particular intensities can flow toward forum influencers, or from them to other members. white knight recounts one instance of where feedback has affected him personally: I had a young girl of 16 and she posted back after 18 months and she said that “I’d like to say thank you to white knight, because his reply to me about 12 months ago” I’ve printed it out and I put it on the door of my bedroom and I read it every day. (white knight) This kind of feedback also affects the way Champions adjust their approach to specific people. Just Sara says: ‘I’ll get some feedback to say you’ve been really helpful, or that’s not what I meant when I was talking. So there is feedback to give me an idea of my role.’ (Just Sara). A key skill for peer influencers is knowing how to manage and modulate feedback. Gruffudd explains the multiple layers of referential reinforcement from his perspective: When you see someone make a positive statement or a statement saying that they enjoy something or value something [from the forum], repeating that back, summarising that back to them and letting them just see their own words and 14 value that, it’s a powerful thing, really. (Gruffudd) As public expression, feedback plays an important role in reinforcing and building a personal and public sense of value as Champion. That is, it not only ‘makes it all worthwhile’ as Starwolf puts it, these are the visible markers of legitimacy, authority and expertise – they ‘visiblise’ expertise and influence. Because the forums are searchable and stand as a record of conversations, and generalisable emotional and mental states, their impact can be made durable over time. Impact is hence able to move beyond the immediate sphere of interaction and influence through this expressed durability. Conclusions: From engagement to influence Mental health organisations have used social media mechanisms like forums for some time now to scale services and maximise affordances such as anonymity and 24/7 peerbased support. With tensions around the negative emotional impact of dominant social media platforms like Facebook, Instagram and Twitter, the community orientation of health forums deserves greater scrutiny. Furthermore, ‘we need to take seriously the cultural production of legitimacy’, as Smith Maguire and Matthews have argued in their review of research on the characteristics and effects of cultural intermediaries (2012: 558). The same could be said for health influencers and of the impact of the affective labour they expend. In the context of online mental health support, understanding the production of legitimacy, expertise and influence among peer mentors is a crucial step toward building better digital interventions. While a critical lens could be levelled at organisations’ reliance on free labour for mental health support, by doing so they offer an opportunity to intervene differently in the flow of negative affect and painful emotional states. With scaled online mental health support comes the question of who is able to take on the role of supporting others through chronic mental health conditions in the community, through community forums and other social media channels. Contributing to an emerging field of work on moderation and work on influencers, the analysis shows that health influencers act in beyondblue’s mental health forums in ways that establish authority and legitimacy, frame and re-frame actions through empathy practices that sustain impactful connections. Champion white knight, sums up the capacity, drive and skill sets involved: I may not be able to work but I have this information to spread and assist if I can. Having mental illnesses doesn’t mean it’s all bad news. Mental illness has provided me with empathy, kindness and care. These are the things I can do without feeling drained and tested. (white knight, Forum: Welcome & Orientation) 15 Motivations for participating in this way vary, but the impact and benefits are demonstrable: ‘By assuming socially valued identities, [supportive peer mentors] are no longer restricted to passive patient roles relying solely on mental health professionals for direction and advice’ (Campbell, 2005: 34, citing Roberts et al., 1991). As an early advocate of peer mentor programs put it: ‘Our emotional life is no longer somebody else’s, the medical profession’s specialty. We are the experts’ (Zinman, 1987: 11; cited in Campbell, 2005: 40). Influence and impact derive from a practiced and cultivated expertise, the developed set of skills or competencies for dealing with mental health issues through public digital platforms, along with an explicit willingness to apply these in helping others through the forums. 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