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Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions

BMJ 2004; 328 doi: (Published 13 May 2004) Cite this as: BMJ 2004;328:1166

Methodology, Validity, and Applicability: A Critique on Eysenbach et al.

We commend Eysenbach and his associates for their intensive
investment in searching, collecting, screening, and investigating studies
on Internet peer-to-peer support groups. These online communities have
become a common source of emotional support for millions of people in
distress. The authors' exhaustive search and careful analysis have been
badly needed, and warrant appreciation from the scientific and clinical

In some ways we are troubled, however, by the rigorous and
unwarranted inclusion criteria used by these authors. For their analysis,
Eysenbach et al. made a careful attempt to include only well-designed
research studies that utilized specific experimental methodology. This
approach, in their view, enabled valid assessment of the sole, incremental
effects of peer-to-peer support. In our view, the authors have isolated
online support intervention effects from reality. Emotional support is not
provided in a vacuum. Online support—by all common theories, methods, and
applications—is most commonly offered to people as an adjunct to other
available resources. Actually, supported by empirical research, a
combination of online support and the use of other help resources is
considered most desirable (e.g., Cummings, Sproull, & Kiesler, 2002).
We strongly believe that online emotional support may be an effective
means of relief, but not as an isolated remedy. Although full control of
variables is commonplace among experimental psychologists (for good
methodological reasons in executing pure experimental designs), it is far
less important in research that seeks to investigate the psychosocial
effects upon real people in distress in their natural social environment.

Secondly, although clinicians and scientists strive at obtaining
reliable evidence, we question whether certain types of quantitative
research on Internet peer support groups are desired, needed, or even
possible. Eysenbach and associates wrote: "Given the abundance of
unmoderated peer to peer groups on the internet, research is required to
evaluate under which conditions and for whom electronic support groups are
effective… (p.1166).” However, as we see it, research of online peer-to-
peer support groups by professionals is rather paternalistic, and it
completely misses the point that the Internet environment is viewed by its
users as a self-empowering medium. Users do not necessarily want, or need,
professional researchers present in peer-to-peer support groups, which are
run by ordinary people for ordinary people. Many of these groups thrive
precisely because there are no professionals in them. Moreover, we
question whether researchers can truly “evaluate under which conditions
and for whom (p. 1170)” online groups are effective given the inherent
nature of these groups, characterized by minimal control, open-door
approach, and unidentifiability (e.g., Wright & Bell, 2003). Eysenbach
et al. also stated that research is needed on “how effectiveness in
delivering social support electronically can be maximised (p. 1166)" but
disregarded the given non-paternalistic, self-help nature of these groups.
The problematic attributions made by Eysenbach et al. make the premise of
their analysis shaky, perhaps unjustified. Moreover, we argue that
professionals are not responsible for maximizing or delivering benefits in
a self-help system and ought to practice appropriate boundaries. The
online peer-to-peer support group environment would apparently benefit the
most by nurturing, respect, and privacy, rather than intrusive external
interventions in an emotionally vulnerable setting. Thus, qualitatively-
oriented and ethnographic methodologies (Hine, 2000) seem to better fit
this special area of research in cyberspace.

Members and leaders of online groups could, however, benefit from
guidelines derived from extensive field experience. Published indicators
of quality would help them educate themselves on factors that might
improve their online peer-support experiences and minimize their risk.
Examples of such guidelines are provided by Grohol (2001), Madara (2004),
and Pector (2004). These resources, as well as other writings on online
support groups which based on experience and appropriate research (e.g.,
Alexander, Peterson, & Hollingshead, 2003; Lieberman & Russo, 2001
-2002; Till, 2003), note that the tone of interaction depends on the
quality of moderation by either naturally emerging leaders or professional
moderators. Most of the studies in Eysenbach et al.’s review, however,
involved professional moderation, whereas the vast majority of Internet
groups are unmoderated. Indeed, the rapid disclosure of intimate personal
details fostered by the online disinhibition effect (Suler, 2004) may
leave participants vulnerable to deception, coercion, anger, and criticism
that can arise in unmoderated groups. We believe a review of existing
qualitative and quantitative studies would offer valuable advice to self-
help communities on how best to create a positive, healing environment and
avoid abuse.

Numerous systematic and nonsystematic observations—and our own
clinical experiences—reveal that online support groups provide much relief
to people who struggle with a variety of mental- and health-related
difficulties. Most of these people do use other resources of variable
quality, from personal therapy, to medications, to support by family, to
worship, to use of amulets, to escape into drugs or gambling. An
investigation that aspires to closely study effects of online support
should not ignore or adjust for these other resources, but should
integrate them into the research design. This results in ecological
validity, documenting the extent to which the conditions under
investigation reflect real life and natural circumstances. Contrary to
Eysenbach et al., we believe that interaction effects of participation in
online support groups and other sources of help have significant impact
and should be included in systematic analyses. Lastly, we encourage
thoughtful methodical reviews of qualitative research already conducted on
online groups. Qualitative studies have described characteristics of those
who use such groups, the process by which self-help occurs, perceived
benefits, potential risks, and the types of individuals that may be helped
or harmed by online support communities. Such information, in addition to
appropriately- and specifically-designed quantitative studies, will help
health professionals intelligently advise patients who use online support


Alexander, S. C., Peterson, J. L., & Hollingshead, A. B. (2003).
Help is at your keyboard: Support groups on the Internet. In L. R. Frey
(Ed.), Group Communication in Context: Studies of Bona Fide Groups (pp.
309-334). Mahwah, NJ: Erlbaum.

Cummings, J. N., Sproull, L., & Kiesler, S. B. (2002). Beyond
hearing: Where the real-world and online support meet. Group Dynamics, 6,

Grohol, J. (2001). What to look for in quality online support groups.
Retrieved on May 16, 2004, from:

Hine, C. (2000). Virtual ethnography. London, UK: Sage.

Madara, E. (2004). How to develop an online support group or Web
site. Retrieved on May 16, 2004, from:
Azy Barak

Pector, E. (2004). Internet support networks: Suggestions for a safe
& sound experience. Retrieved on May 16, 2004, from:

Suler, J. (2004). The online disinhibition effect. Retrieved on May
16, 2004, from:
Till, J. E. (2003). Evaluation of support groups for women with breast
cancer: importance of the navigator role. Health and Quality of Life
Outcomes, 1, (16). Retrieved on May 16, 2004, from:
Wright, K. B., Bell, S. B. (2003). Health-related support groups on the
Internet: Linking empirical findings to social support and computer-
mediated communication theory. Journal of Health Psychology, 8, 39-54.

Azy Barak, Ph.D.

Fellow, International Society for Mental Health Online

Departments of Psychology and Education,
University of Haiha,
Haifa 31905, Israel

John M. Grohol, Psy.D.

Fellow, International Society for Mental Health Online

39 Colby St.
Bradford, MA 01835

Elizabeth Pector, M.D.

1220 Hobson Road, Suite 216,
Spectrum Family Medicine,
Naperville, IL 60540

Competing interests:
None declared

Competing interests: No competing interests

17 May 2004
Azy Barak
Professor, University of Haifa
John M. Grohol, and Elizabeth Pector
Departments of Psychology and Education, Unversity of Haifa, Haifa 31905, Israel