Understanding the needs of moderators in online mental health forums: a realist synthesis and recommendations for support (Preprint)

BACKGROUND There has been an increase in the use of online mental health forums to support mental health. These forums are often moderated by trained moderators to ensure a safe, therapeutic environment. While the moderator role is rewarding, it can also be challenging. There is a need to understand the impact of the role on moderators and how they can best be supported to maintain psychological well-being. OBJECTIVE Understand how, why, and in what contexts moderator well-being is affected by the moderator role and produce actionable recommendations for how moderators can best be supported to maintain workplace psychological well-being. METHODS Realist synthesis of published and grey literature from 2019-2023, stakeholder interviews with forum moderators and hosts, and moderator training manuals developed by organisations that host online mental health forums. Self-determination theory (SDT) was used as the theoretical bases for this synthesis. RESULTS We developed 32 CMOCs from our realist analysis of 9 published papers, 18 interviews and 5 training manuals. Findings highlight ways moderator well-being can be supported by meeting the psychological needs for autonomy, competence, and relatedness. Forums which allow moderators to work in alignment with their own values and motivations can increase moderator well-being. Forum organisations should support moderator competence through initial expectation setting, especially around moderator responsibility for user well-being, and ongoing support such as meaningful supervision and peer support. Co-designed training, reflective practice and experiential learning are all key for increasing moderator competence and satisfaction in the workplace. Ensuring adequate staffing, teamwork and innovative forum design can increase moderator psychological well-being. Organizational support for moderator well-being through monitoring and encouraging self-care are vital to ensure moderators can effectively carry out their role. Making and supporting meaningful relationships in the forum can boost psychological well-being and the therapeutic value of the moderator role. Key challenges for moderators were: dealing with conflicts between supporting open discussion and ensuring a safe community environment; sharing lived experiences in positive ways for both moderator and user; and supporting people with the limitations of an anonymous forum. CONCLUSIONS This realist synthesis is the first to examine the impacts of being a moderator of online mental health forums on moderator well-being. Recommendations to support moderator psychological well-being are proposed, targeted at specific stakeholder groups to aid implementation. Organisational level endorsement and facilitation of support is particularly important for the realization of recommendations and interventions to support moderator well-being.