Understanding the Needs of Moderators in Online Mental Health Forums: Realist Synthesis and Recommendations for Support.

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: This study aimed to 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: We conducted realist synthesis of (1) published and gray literature from 2019 to 2023, (2) stakeholder interviews with forum moderators and hosts, and (3) moderator training manuals developed by organizations that host online mental health forums. Self-determination theory was used as the theoretical basis for this synthesis.

Results: We developed 24 context-mechanism-outcome configurations from our realist analysis of 9 published papers, 18 interviews, and 5 training manuals. The findings highlight the specific ways in which moderator well-being can be supported through meeting the psychological needs for autonomy, competence, and relatedness. Forums that allow moderators to work in alignment with their personal motivations can increase moderator well-being. Forum organizations 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 to increasing moderator competence and satisfaction in the workplace. Working within a diverse team with access to innovative forum design can increase moderator psychological well-being. Organizational support for moderators' well-being through monitoring and encouraging self-care is 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 within the limitations of an anonymous forum.

Conclusions: This realist synthesis is the first to examine the impacts on well-being of being a moderator of an online mental health forum. Recommendations to support moderator psychological well-being are proposed, targeted at specific stakeholder groups to aid implementation. Organizational-level endorsement and facilitation of support are particularly important for the realization of recommendations and interventions to support moderator well-being.