The promise of anonymity helps to eliminate barriers stopping people from finding mental health support. It brings people to our service who may never otherwise ask for help.
It means we can provide early, preventative support to more people, keeping more people safe. People who are struggling with an eating difficulty, who feel hopeless, who are anxious, who can’t sleep, who are desperately lonely - and sometimes who only feel able to tell their story with the perceived protection anonymity brings.
Preventative and accessible services are vital for population health
Shaping early intervention mental health services which can be accessed in minutes and without stigma is key to prevention, which is in turn critical to creating healthier populations.
As Sean Duggan, chair of Sussex Partnership NHS Foundation Trust, put it:
“The earlier you can intervene, the better it is. It's the same for cancer, the same for heart disease. and it's the same for mental health issues.”
We are only too aware of the serious impacts on individuals, families, communities and whole populations when mental health support is not sought, is unavailable or is not known about. The likelihood of issues escalating or becoming entrenched increases, leading to greater need for acute or crisis support.
Being ‘unknown’ can promote help-seeking
We believe anonymity is a key element to prevention, a belief reinforced time and in research with our service user communities. According to a recent survey, 97% of young people said it was important that they could be anonymous on Kooth. Indeed, being unknown, even partially, can be the very reason someone is able to share their struggle.
“Kooth has been a lifeline for me. I've always struggled with my mental health but never able to ask for help. For the first time in years I've reached out and already I've been given the opportunity to live chat…If it wasn't anonymous I wouldn't have been able to reach out.” Young person on Kooth
The safety aspect highlighted by this young person is critical. People - and young people in particular - can be naturally fearful of what it means to open up to ‘authority figures’ like doctors, teachers or other ‘trusted adults’.
Many individuals worry about stigma and judgement - as well as losing control over their future if they disclose mental health problems. Some may not trust those around them, perhaps with good cause.
It is vital that people who come to us for help are safe in doing so.
Charlie’s story
Charlie came to Kooth for help after moving out of her Mum’s house to live with a foster family. This was her second foster home; she moved out of her first after feeling she didn’t have a good relationship with her carers - a feeling that was impacting her ability to trust adults.
Charlie felt a lack of trust with her new foster carers and missed her Mum. She was experiencing thoughts of self-harm and was feeling anxious around other people.
Being able to access anonymous support online through Kooth meant Charlie could manage her difficulties with confidence and trust and feel in control of the relationship.
In one-to-one chats with Kooth practitioners, Charlie began to break down barriers around trusting adults and take some steps to getting help from her foster carers and from her school.
Through direct risk enquiry, it was established that Charlie experienced thoughts of self harm but shared there was no intent to act on these. Risk was continuously assessed.
With her practitioner, Charlie went on to explore the triggers for her thoughts of self-harm, explored other coping strategies and made a safety plan. She has been working with practitioners to build her confidence using affirmations and creative writing.
Charlie is now feeling safe and has spoken to her foster carers and school. She is using the peer support area on Kooth to tell her story and to help others.
According to Dr Hannah Wilson, Clinical Psychologist and Head of Clinical Governance at Kooth, it is not uncommon for people seeking mental health support to value the sense of control and safety anonymity brings:
“Digital therapy is sometimes felt to be the ‘safer’ path and therefore is one people may feel less self conscious or worried about taking. In this respect, anonymity is an important way to ensure there are fewer barriers in the way of someone finding help when they want it. Making it easy to get that help and giving people autonomy over their mental health journey can be transformational.”
How we safeguard people who are anonymous and at risk
Safeguarding our communities online is paramount. Although we are primarily an early intervention and prevention service, we often support high levels of risk.
Indeed, our severity and presenting issues data indicates that many of our users would not meet the high threshold for onward referral and yet still need timely support to prevent escalation of difficulties.
Specifically, in relation to risk to self, our practitioners make routine enquiries into suicide and self-harm risk in every one-to-one session. If an individual shares something that constitutes a safety concern, we ask for their name and address to help us safeguard them, though as outlined above, sometimes not sharing can be a protective factor for some.
All practitioners are able to make referrals to Early Help, Social Care, and other local services which aim to ensure that services to support children, young people, adults and families are available when needed.
Practitioners have access to local authority details to make such referrals, and will do so through collaborative decision making using our safeguarding escalation process, including calls to the police and ambulance services for ‘welfare checks’ when immediate risk is presented and the person is known.
Dr Wilson: “Safeguarding is front and centre for us; we do everything in our power to keep people safe. In cases where we need to ask for someone’s name and address, this is often freely shared as our practitioners will have developed trusting relationships with individuals they support. Where this information isn’t given, we will do everything to hold that person safely, working with them to create a safety plan as well as signposting them to crisis services which offer support.”
Anonymity can offer vulnerable people a greater sense of safety and control
Anonymity can offer a real sense of safety and control, which can be especially welcome in the context of mental health, which can be associated with stigma and shame. Feedback from our Kooth users has consistently supported this. We know from suicide data that most people who take their own lives are known to services, showing that ‘being known’ isn’t enough of a protective factor.
For those who may have experienced childhood sexual abuse for example - many of whom take years to disclose abuse if at all - anonymity can help build the trust necessary for them to open up and begin to process their feelings.
A recent research report from the Government's Medicines and Healthcare Products Regulatory Agency looked at user and public perspectives on digital mental health technology. Anonymity was one of the features which young people mentioned most often.
According to the report, “They [young people] valued the opportunity to speak anonymously, in part because it avoided embarrassment or feeling judged, in part because it allowed them to remain in control of the process, compared to speaking to, for example, a teacher who then might feel obliged to inform their parents.”
“I think Kooth is great and I like its anonymous so you can't feel judged and I feel more confident giving and getting advice from people I will never meet.” Young person on Kooth
Finding safe help that feels right
Whatever issue an individual brings to Kooth and whatever the level of risk, everyone on our site is able to exercise autonomy in the type of help they access.
They may choose a one-to-one chat with a Kooth counsellor, but equally could find peer support or therapeutic content helpful. Whatever feels right and ‘works’ best for each individual means everyone can forge their own path.
Importantly, this activity is contained in a safe space. It’s not possible for anyone to communicate directly to another person on the site. We have a team of professional moderators reviewing all comments and submitted content before assessing whether it is safe and appropriate to publish.
This protected environment means service users know they won’t receive a negative comment or read dubious ‘advice’ if they post a question or an article. With age-gated content and moderation, we can be sure that children and young people only see material that is appropriate to them.
Dr Wilson: “Creating a sense of safety is so important for our community, who can be feeling vulnerable in a million different ways. Knowing that there are no negative comments and no way to send or receive personal messages from other service users - and that there is a team of professional practitioners on hand to help - is hugely reassuring. This sense of being in a safe and anonymous space with others is particularly helpful for those who may feel marginalised, misunderstood and/or alone with their feelings.”
Anonymity helps seldom-heard groups find help
As an anonymous service and one with a strong inclusivity principle, Kooth has seen success in reaching seldom heard groups. Data from our user survey (Dec 2022 - Jan 2023) shows 19% of service users were from ethnic minority backgrounds and that 7.5% identified as non-binary, both significantly higher figures than those accessing traditional services.
Dr Wilson: “Anonymity can be a powerful source of reassurance to people who worry about reaching out for mental health support, maybe because of stigma around their culture or faith, maybe because of previous negative experiences. If someone is already feeling marginalised, a degree of anonymity can give them enough confidence to ask for help.”
Do people share more when they’re anonymous?
There is a phenomenon known as ‘the online disinhibition effect’, where people tend to behave in a more uninhibited way when communicating online. They might be more likely to share their thoughts, beliefs and feelings that they may be otherwise too embarrassed about to express in person.
This can be beneficial, freeing individuals up to articulate thoughts and feelings they may not feel able to verbalise.
Dr Wilson: “Therapy can be a good place for people to 'experiment’ safely with their thoughts, perhaps about who they are or what they believe. The disinhibition effect is also something we’re mindful of, however, as people can feel overwhelmed after revealing something deeply personal, sometimes quite soon in the client-therapist relationship. What is important is that the practitioner offers non-judgemental support throughout and goes at the right pace for the individual they’re helping.”
Unknown and understood
Now more than ever, we are determined to push for equity of awareness and availability of professional mental health support for anyone in need. We believe digital mental health support - delivered with anonymity, whether full or partial - - is a key component in realising this vision.
To equip all of us with the resilience and psychological flexibility necessary to lead a fulfilling life, early and freely available help with no barriers, no waiting lists and no thresholds has to be the goal.
“I feel safe talking about things with the Kooth counsellors. Being anonymous helps me to feel comfortable and it's harder for me to open up to someone in person.” Young person on Kooth