Abstract

The purpose of this research was to use Web-based survey methodology to examine the use of information technology (IT) by people with psychiatric disabilities, as well as its association with self-determination in their lives. Survey respondents were recruited via notices posted on mental health listserves and Web sites as well as through newsletters and emails. A total of 911 respondents completed the survey. Respondents reported diverse uses of the Internet, in some cases exceeding usage reported by the general population. A positive association was identified between frequency of Internet use and self-assessed degree of self-determination. In multivariate analyses controlling for demographic variables (including income and education) and impairment indicators (including hospitalization history), those with higher self-determination were significantly less likely to hold negative attitudes about Internet use. Many respondents reported using IT to advocate for themselves, as well as to organize others in groups that can advocate for each other.

Key Words: self-determination, mental illness, Web survey, Internet, psychiatric disabilities

Introduction

The purpose of this research study was to survey Internet users with psychiatric disabilities regarding issues related to their use of information technology (IT) and its connection to self-determination in their lives. A Web-based survey was created and administered by the University of Illinois at Chicago (UIC) National Research and Training Center's (NRTC) Self-Determination and Technology Workgroup, comprised of mental health service consumers, advocates, and researchers interested in the application of IT to mental health issues. The study was designed to yield information that would be of use to those seeking to better understand how IT can enhance individual self-determination, to identify access gaps that exist and how to address them, and to appreciate the potential of IT applied to mental health advocacy efforts.

Review of the Literature

In American society today, new information is being distributed at an unprecedented rate that is increasing exponentially due to advances in IT, particularly use of the Internet. Numerous studies have pointed out the diverse uses of the Internet in commercial, political, economic, domestic, and community participation activities (Harrison & Stephen, 1999; Katz & Rice, 2002; Sudweeks, McLaughlin & Rafaeli, 1998; Waipeng & Eddie, 2002). This has led to concerns about maximizing access to IT by a wide variety of stakeholders, especially consumers of rehabilitation services (Fullmer & Mujumder, 1991). Similarly, there is growing recognition in disability disciplines that the gap between access to knowledge and knowledge application can impede both consumers' personal progress as well as innovation in service settings and systems (Zeren et al., 1999).

While the use of technology, such as personal computers and electronic networking, may serve as a cost effective way to gather information, many people lack access to these new technologies, leading to the much-discussed "digital divide." According to the U.S. Census Bureau, more than three-quarters (79%) of U.S. households with incomes above $75,000 a year use the Internet at home while less than a fifth (19%) of households with incomes below $25,000/year have Internet access (Neuberger, 2001). In addition to income, a host of other factors separate Internet users from nonusers, according to surveys conducted by both the Census Bureau and The Pew Internet and American Life Project (Lenhart et al., 2003; Neuberger, 2001). Those more likely to be online are younger, Caucasian, have formal education beyond high school, live in suburban or urban (versus rural) communities, and reside in households with children (Lenhart et al., 2003). Another important finding is a relationship between social factors and Internet use. Those who feel more in control of their lives are more likely to use the Internet than those who feel they do not have control over their lives; and those who trust others and have numerous sources of support are more likely to use the Internet than those who are less socially content (Lenhart et al., 2003). Other barriers to Internet use include low literacy rates, inadequate computer education, lack of high-speed equipment, and scarcity of culturally relevant information on the World Wide Web, all of which impede the appeal and utility of the Internet for many communities (Foxhall, 2000).

These findings assume added importance when viewed in the context of the social and economic position of Americans with disabilities in the U.S. This is because disabled citizens have lower education, employment, household income, and social integration than nondisabled individuals, the very same features associated with lower Internet access in the general population (Kaye, 2000). Thus, it is not surprising that surveys of Americans with disabilities find that they have one of the lowest levels of Internet access in the U.S. (Lenhart et al., 2003). Using Census data collected in 1998-1999, Kaye (2000) found that, among people age 15-64, only 15% of people with work disabilities reported having access to the Internet while over two-fifths (42%) of those without disabilities did so. Using data collected in 2000-2002, the Pew national telephone survey found that 38% of those with disabilities go online compared to 58% of those without disabilities (Lenhart et al., 2003). Both surveys found that, when they did use the Internet, individuals with disabilities were more likely to go online at home and less likely to use the Internet outside the home than those without disabilities.

Close to a fifth of individuals with disabilities (19%) report that their limitations make Internet use difficult (Lenhart et al., 2003). Moreover, 21% of respondents with disabilities agreed strongly that the Internet is confusing and hard to use and 25% strongly agreed that it is too expensive, contrasted with 19% and 18% of their non-disabled counterparts (ibid.). There is also evidence that those with disabilities use the Internet somewhat differently. For example, compared to nondisabled users, disabled Internet users are more likely to be recent users, less likely to purchase products or look for leisure information online, and more likely to look for medical information, play games, and search for information about a person online (Lenhart et al., 2003). Finally, among Americans with disabilities, Internet access is lower among older, unemployed, less educated, low income, and African American individuals (Kaye, 2000).

There is also evidence that individuals with psychiatric disabilities have limited access to the Internet. Foxhall (2000) describes programs designed to increase access for people with mental health problems including a program in Los Angeles where women clients at an inner-city mental health program were introduced to the Internet and taught how to access Web sites to help them deal with problems of daily living. A study of individuals with serious mental illness who were learning to use individualized Web portals to explore mental health issues (Farrell, Mahone & Guilbaud, 2004) found that study subjects sought information about medications, emergency services, stress reduction, and family support. Participants were also interested in communicating with their service providers via email and using chat rooms with other mental health service consumers to give and receive support. Campbell (1997) surveyed 30 mental health consumer-run programs nationwide to determine their management information system needs and found that, while most (90%) used computers for activities such as correspondence (80%), bookkeeping (63%), and data collection (60%), less than one-third (30%) reported being online. In a study of mental health service consumers and providers, Dansky et al (2001) found that low-level use of the Internet by persons with psychiatric disabilities was directly attributable to the lack of technology resources available at the agencies where they received services. The President's New Freedom Commission on Mental Health Report (Hogan, 2003) noted that use of technology in mental health care is lagging and recommended that consumers' access via the Internet to mental health information and providers be significantly enhanced.

While emphasis is placed on the benefits of Internet access, there have been debates about the potential for social disengagement and other possible harmful effects of Internet use. In a longitudinal study of new Internet users, Kraut et al (1998) found that depression and loneliness increased with Internet use, while social involvement decreased. They termed this the "Internet paradox" because the Internet, often seen as a "social technology," appeared to have a negative impact on social and psychological outcomes. In a later research study, LaRose et al (2001) presented alternative explanations for the "Internet Paradox." Their results indicated that depression can be alleviated through Internet communication with known individuals, particularly among those who are already socially isolated or moderately depressed. Additionally, it was found that stressful interactions with the Internet may have contributed to depression in novice users, and that self-efficacy reversed the effects of this stress. To that end, in a 3-year follow-up with the participants of the original Internet Paradox study, Kraut et al (2002) found that the earlier negative effects of Internet use on social involvement and psychological well-being had dissipated. Additional debates continue regarding the idea that the Internet bestows benefits to all who use it. For example, Goggin and Newell (2003) challenge the notion that technology is the "answer" for people with disabilities, and note that disability is constructed, in part, through technology.

In addition to its focus on Internet use as a topic, this study also used Internet survey methodology by recruiting respondents and administering the survey via Web technology. This methodological approach was taken for several reasons. First, the Internet has been shown to be useful for studying specialized, difficult-to-reach populations (Kraut, Banaji, Bruckman et al., 2004) such as members of socially stigmatized communities who might hesitate to self-identify and permit face-to-face contact with researchers (Murray & Fisher, 2002; Subramanian et al., 1997). In one study, researchers soliciting a gay and lesbian sample for a study of sexual behavior were successful in using a Web-based approach to collect one of the largest such samples to date (Epstein & Klinkenberg, 2002). Second, use of the Internet to collect data affords research participants a degree of anonymity and confidentiality that exceeds many other approaches such as face-to-face interviews or even mail surveys (Fawcett & Buhle, 1995). For example, in one Internet survey of oncology nursing experts (Im & Chee, 2002), ensuring anonymity was relatively simple given that data collection consisted entirely of anonymous communication with the researchers in completing and submitting survey responses. Third, research via the Internet is associated with less social pressure due to lack of interaction with and distance from the researcher (Kraut et al., 2004). In comparing responses of research participants to paper and pencil versus Web-based surveys, Joinson (1999) found that respondents reported lower social desirability and social anxiety when data were gathered via the Internet. These advantages, however, must be weighed against disadvantages of Web-based surveys including problems of self-selection leading to sample and response biases (Gonzalez, 2002), inability to monitor drop-outs (Birnbaum, 2004), low response rate (Ranchhod & Zhou, 2001), lack of control over the data collection setting (Kraut et al., 2004), and difficulties in protection of human subjects (Im & Chee, 2004).

The primary purpose of this study was to explore the use of IT by people with psychiatric disabilities, specifically the Internet, as well as how this was related to self-determination. Three basic research questions were addressed. First, how and where do people with serious mental health problems access the Internet and for what purposes do they use it? Second, what respondent background features are related to their frequency of Internet use and number of years online? Third, what are respondents' attitudes toward Internet use and degree of personal self-determination in their lives, and what interrelationships exist between the two? The following section describes the procedures used to address these research questions.

Methodology

Sampling strategy: A convenience sample was obtained through announcements posted to a number of mental health listserves and Web sites, sent to members of the NRTC mailing list, and advertised in newsletters targeted to people with psychiatric disabilities and other mental health stakeholders. This announcement explained the purpose of the survey, described eligible respondents, and directed interested participants to a secure Web address where they could complete the survey online with complete anonymity. Potential respondents with questions or those having difficulty completing the survey were provided with contact information for UIC NRTC staff.

Web survey procedures: The survey Web site could be visited by anyone with access to the Internet. At the Web site, participants were presented with a series of survey questions that took approximately 10 to 20 minutes to complete, depending on the "skip pattern" created by replies to certain questions. As surveys were completed and submitted, each respondent's information was automatically entered into a secure and protected database, accessible only to the UIC research staff. The survey Web page and database were hosted with WebSurveyor Corporation, a private, for-profit research firm. All transmitted data were encoded using Secure Sockets Layer encryption. No Internet Protocol (IP) addresses linked to specific hardware used to complete the survey, nor any other identifying information about the respondents were collected. All research procedures were reviewed and approved by the University of Illinois at Chicago Institutional Review Board.

Inclusion and exclusion criteria: Individuals eligible to complete the survey were those who self-identified as having experienced mental health difficulties, those reporting a diagnosis of mental illness or use of psychotropic medication, and/or those who said they had been hospitalized for mental health reasons. Exclusion criteria included individuals who could not read English, those without access to the Internet, individuals who did not self-identify as mental health consumers, and minors (given human subjects requirements of parental consent, all information from individuals indicating that they were less than 18 years of age was excluded). The survey was posted for 9 months from July 2003 through April 2004.

Survey instrument: The Web-based survey was programmed using a "dynamic" or interactive format (Tourangeau, 2004) and included automated skip patterns, immediate range and error checks, forced responses to all applicable items, and respondent-generated data submission. Survey items were adapted from those used by the U.S. Bureau of the Census in its Technology Survey (Neuburger, 2001) and from the Pew Internet & American Life Project surveys (Fallows, 2000). Other items were created by the UIC NRTC project workgroup. The survey was comprised of three basic sections. The first section elicited respondents' feelings about the degree of self-determination in their lives by asking respondents: 1) two open-ended questions about what fostered and impeded their own self-determination; 2) closed-ended questions about different aspects of self-determination such as control over finances, residential status, and treatment; 3) to rate the degree of self-determination in their lives on a scale from 0 to 10; and 4) about their level of self-determination as it related to receiving mental health services. Those not receiving services responded to a separate set of questions asking why this was so. The second section asked about respondents' access, use, and barriers to use of information technology. The third section asked about respondents' demographic characteristics (including gender, age, education, and racial/ethnic background), as well as features of their clinical history (such as psychiatric diagnosis, co-occurring disabilities, prior psychiatric hospitalizations, and whether they were receiving mental health services). A draft version of the survey was field-tested and revised according to psychometric results and field-test respondents' feedback. The present analysis used data from the survey's second and third sections, along with the 0-10 rating of self-determination from the first section.

Analysis: After inspection of frequency distributions and descriptive statistics, Pearson correlation was used to determine interrelationships among respondents' background characteristics, frequency of Internet use, and attitudes toward the Internet. Next, responses to four attitudinal items were used to create a summary measure of overall comfort with Internet use, and multivariate logistic regression analysis was used to examine associations between this summary attitudinal measure and respondents' self-rated level of self-determination, while controlling for a number of respondents' background characteristics.

Results

Supplemental results tables for this article are available at: http://www.psych.uic.edu/uicnrtc/cook.DSQ.tables.pdf.

Characteristics of the respondents: A total of 911 individual respondents completed the survey and met study inclusion criteria. The majority of respondents reported a specific diagnosis of mental disorder (100%), said they had taken or were currently taking psychotropic medication(s) (100%), and/or reported one or more mental health hospitalizations (73%). A much smaller proportion (13%) reported one or more substance abuse related hospitalizations. Most (86%) reported currently receiving mental health services and most (69%) felt that their mental health problems currently limit their life activities, while close to a third (32%) reported that another disability currently limits their life activities. Most respondents (87%) were Caucasian, with smaller proportions of Hispanic/Latinos (3%), African Americans (2%), those with mixed ethnicity (3%), Asian Pacific Islanders (1%), and other race/ethnicities (4%). Three-quarters (76%) were female, and their average age was 43 years (with a range from 18-72 years). Most were single, with only 38% reporting being married or cohabiting. The large majority (98%) had completed high school or a General Equivalency Diploma (GED). Half (51%) were employed (35% full-time and 16% part-time). Around a third (32%) had household incomes less than $15,000/year, while only 25% reported household incomes greater than or equal to $50,000/year. A third (34%) lived in urban areas, two-fifths (42%) in suburban communities, and a quarter (24%) resided in rural communities. In addition to their status as individuals with mental health problems, 38% reported that they were mental health advocates, 38% were relatives of someone else with mental health problems, 12% were program directors, 13% were service providers, 17% were students, 9% were researchers, 10% were teachers, and 12% did consulting.

Degree of personal self-determination: As defined in the survey instructions, the concept of self-determination referred to the freedom to be in charge of one's own life including the ability to make decisions about one's finances, place of residence, friends, and activities. It also meant having the resources to create a good life, make responsible decisions, and choose where and how one received services and support for mental health problems. When asked to rate their level of personal self-determination on a scale from 0 to 10, the mean response was 6.65 (median=7), with only 18% rating their self-determination as less than 5, and 22% rating it as 9 or 10.

Reported use of the Internet: As expected, given the nature of the study as an Internet survey, the large majority of respondents (97%) said that they had used a computer previously (other than to complete the survey), 85% reported owning their own computer, and 91% said they have access to a computer they can use whenever they wish. Almost all of the respondents (98%) said they had been on the Internet before (other than to complete the survey). Among those who reported Internet use, the average length of time respondents had been going online was 6 years (median=6), with a range from 1 to 20 years. When asked about their frequency of Internet use, almost two-thirds (64%) reported using the Internet several times a day, 19% said they use it once a day, 10% reported use on 3-5 days per week, 4% 1-2 days per week, 2% every few weeks, and 1% less often.

Awareness of free and commercial Internet access: Respondents had a high level of awareness of free (85%) Internet access in their communities. A large majority (82%) were aware of free access at a public library, 22% at a college/university/other school, and 21% at a mental health or peer support program. Much smaller proportions were aware of free access at a church (3%), employment setting (9%), or some other place (6%). Perhaps because most owned their own computer, a smaller proportion (46%) said they knew where they could use the Internet for a fee (i.e., pay-as-you-go usage). A quarter (25%) were aware of an Internet café, 33% a business service center, 11% a coffee shop, and 5% some other place.

Locations of Internet access: Respondents reported accessing the Internet at a number of different locations. The most common location was home (85%), followed by work (47%), a public library (27%), someone else's privately owned computer (19%), at a school (12%), at a mental health or peer program (11%), or some other place (3%). Only 3% reported accessing the Internet using a wireless device.

Uses of computers and the Internet: Survey respondents reported numerous uses of computers and the Internet. The most frequent uses (reported by 90% of respondents or more) were to obtain health/medical information (97%), search for information on mental health/treatment/medications (95%), to search for information about products or services (95%), to get news online (91%), and to visit government Web sites (91%). Also frequently reported were word processing/desktop publishing (87%), checking weather forecasts (83%), purchasing a product online (76%), and obtaining information about movies, music, or other leisure pursuits (78%). Smaller proportions (less than 50%) reported using the Internet to manage household finances (49%), search for a place to live (49%), do online banking (46%), search for information on job accommodations/supports (45%), view TV/movies or listen to the radio on the Internet (40%), work on school assignments (36%), create artwork (28%), take an online course (27%), or make telephone calls (7%).

Relationships with length and frequency of Internet use: Zero-order associations between respondents' frequency of Internet use, number of years online, respondents' background characteristics, and their level of self-determination revealed a positive and significant relationship in which respondents with a greater number of years online used the Internet more frequently. Those who had been online for a greater number of years also were more likely to be married and have a college degree, and less likely to be members of racial/ethnic minority groups, less likely to have annual incomes less than $15,000/year, to live in rural areas, and to have ever been hospitalized for psychiatric problems. Those who used the Internet more frequently were more likely to be married, and less likely to have annual incomes less than $15,000, to have ever been hospitalized for psychiatric problems, and were less likely to report that their mental health disability limits their daily activities. Respondents with higher levels of self-determination used the Internet more frequently, were more likely to be married, employed, and a college graduate, and less likely to have low annual household incomes, to live in an urban area, to report that their mental health problems interfered with daily living, and to have been hospitalized for mental health or substance abuse.

Relationships with negative attitudes about Internet use: The authors also examined associations between respondents' background characteristics and four attitudinal items expressing reservations about Internet use. Three of these items were taken from the Pew survey of Internet use among individuals with disabilities (Lenhart et al., 2003). The first of these asked respondents whether they felt their mental health problems interfered with their Internet use (in the original Pew survey item, respondents were queried more generically about whether their disabilities interfered with Internet use). The second item asked whether respondents found the Internet confusing and difficult to use. The third queried whether they felt that Internet access was too expensive. The fourth item, created by the UIC NRTC Technology Workgroup, asked respondents whether they considered the Internet to be "dangerous." Those agreeing that their mental health problems interfere with Internet use were more likely than those who disagreed to be single, to have less formal education, to be unemployed, to have lower incomes, to be male, to have been hospitalized for psychiatric reasons, to have a co-occurring disability, and to feel that their mental health problems limit daily activities. Those who agreed that the Internet is confusing and hard to use were more likely to live in a rural area, be single, have less education, be unemployed, have lower income, be male, have been hospitalized for psychiatric problems, and to have a co-occurring disability. Respondents who agreed that the Internet is too expensive were more likely to be single, unemployed, have lower income, have been hospitalized, and have a co-occurring disability. Finally, those who agreed that "the Internet is a dangerous thing" were more likely to live in a rural area and have less formal education. Responses to all four items were significantly correlated with each other.

In order to create an index of self-assessed barriers to Internet use, scores indicating respondents' agreement versus disagreement with the four items were summed to create an ordinal measure. Scores ranged from 0 (disagreement with all 4 items) to 4 (agreement with all items) with a mean of 1.4 (median=1). Next, the distribution was divided at the top quartile to identify those with the highest level of attitudinal barriers to Internet use, comprising 18% (n=151) of the respondents. This index was used as the dependent variable in a multivariate logistic regression analysis with self-assessed level of self-determination as the independent variable, controlling for a number of respondent background characteristics. The results revealed that, controlling for demographic, clinical, and disability features, those with greater self-perceived self-determination reported a lower level of attitudinal barriers to Internet use. In addition, a low level of attitudinal barriers was reported by college graduates, those who were employed, and those who had been online longer. Higher barriers were reported by those who were older and those in rural areas.

Advocates' use of the Internet: Given that more than a third of respondents (38%) characterized themselves as advocates, the final set of analyses examined whether those who said they engaged in advocacy work reported using the Internet differently than those who did not. Inspection of Pearson correlations (not shown) between status as an advocate and Internet uses, significant at p<.05 or greater, revealed that advocates were more likely than non-advocates to report that they used the Internet to obtain health and mental health information, access disability-related information, visit federal government Web sites, obtain information about reasonable accommodations, and search for service providers. They were also more likely to use the Internet or computers to do work, do word processing, send or receive email, participate in chat rooms or listserves, and make phone calls. Advocates also reported using the Internet more frequently than non-advocates and had spent a greater number of years online.

Summary and Conclusions

The results of this study revealed that survey respondents were a highly educated, primarily Caucasian, mostly female group of consumers. Their average age was in the mid-40s, most were college graduates, they resided in urban or suburban areas, and most were computer owners and frequent Internet users. These characteristics mirror many of those found to be associated with greater likelihood of Internet use in the general population reviewed earlier. In addition, the majority of respondents had been hospitalized at least once for mental health problems, were receiving mental health services, and felt that their mental health problems interfered with their daily life activities. This suggests that respondents had experienced significant levels of disability associated with their mental health disorders despite their high levels of Internet use.

Respondents reported diverse uses of the Internet and, in some cases, proportions engaging in different types of usage exceeded those reported in the general population. For example, 95% of respondents with psychiatric disabilities reported searching the Internet for diagnosis-specific and other mental health information while only 21% of the general adult population reported doing so (Fox & Fallows, 2003). Similarly, 91% in this survey said they looked for information from a local, state or federal government Web site while the corresponding figure in the general population was 66% (Horrigan, 2004). Participation in Internet chat rooms and online discussions was reported by a higher proportion of people with psychiatric disabilities (51%) than the general population (25%) (Madden & Rainie, 2003). Moreover, the proportion of respondents who said they had purchased a product online (76%) or got the news online (91%) was higher in this survey than among the general population (61% and 71% respectively) (ibid.). On the other hand, roughly equal proportions reported using the Internet to send and receive email: 90% in this study and 93% in the general population (ibid.). The same was true of using the Internet to make phone calls: 7% in this study and 6% in the general population (Neuburger, 2001). Finally, a greater proportion in the general population reported using the Internet to complete school assignments (53%) (Madden & Rainie, 2003) than among respondents in this study (36%). Overall, however, compared to the general population, large proportions of survey respondents reported heavy Internet use for a wide variety of purposes.

An especially important finding was a positive statistical relationship between frequency of Internet use and self-assessed degree of self-determination. More frequent Internet users reported significantly higher levels of self-determination in their lives. In the general population, Internet users express higher degrees of control over their lives than nonusers (Lenhart, 2003), and a major part of self-determination is the ability to make decisions in important life areas. While it may be tempting to argue that Internet use "causes" greater self-determination or vice versa, this study's methodology does not permit us to make causal attributions. It may be that self-determination and Internet use are interrelated because both are "caused" by a variable indicative of greater personal resources such as income or education, or an indicator of impairment such as limitation on daily activities or hospitalization history. Such patterns do indeed characterize this study's findings. However, the study's multivariate analysis showed that those with higher self-determination were significantly less likely to hold negative attitudes about Internet use, controlling for a host of other factors such as demographic variables (including income and education), and impairment indicators (including hospitalization history). Moreover, in this model both self-determination and number of years online were associated with less negative Internet attitudes.

The study's finding that most respondents used the Internet at home mirrors that of two other large-scale surveys conducted by the U.S. Bureau of the Census and The Pew Foundation. However, even though they had Internet access at home, a sizable proportion (85%) knew where they could use the Internet for free. Moreover, 21% reported that they were aware of free Internet access at a community mental health center, peer support program, or other mental health setting. Thus, people with psychiatric disabilities in this study were knowledgeable about places where they could get free Internet access in their communities, including their community mental health service providers. These results support recommendations made by the President's New Freedom Commission on Mental Health by confirming the great potential inherent in enhancing the mental health system's ability to help its users' access and use IT effectively.

Several study limitations suggest that caution should be taken in interpreting the findings of this research. First, the sample is self-selected and, thus, is not representative of all Internet users with psychiatric disabilities. As such, results should not be considered generalizable to the entire population of interest. Second, it is difficult to determine the extent to which respondents were truthful or accurate when providing information as there was no way to confirm or disconfirm their responses to survey items. Thus, the reliability of the information respondents provided is open to question, although no more so that in any self-report survey regarding Internet use. A third concern is the overrepresentation in the study sample of women, those with college educations, and Caucasians, although this was not surprising given that the last two characteristics mirror those of today's typical Internet user (Lenhart et al., 2003). However, these caveats suggest that further research is required to explore the extent to which the study's results accurately characterize larger and more diverse groups of individuals than those surveyed.

Because almost two-fifths of respondents identified themselves as advocates, it is noteworthy that many appear to be using tools, such as the Internet, that enable individuals to advocate for themselves, as well as to organize others in groups that can advocate for each other. Compared to the "average" Internet user in the U.S., even larger proportions of advocates used the Internet to access health and mental health information, learn about their rights regarding reasonable accommodations, research service providers, visit government Web sites, get news, and send or receive email. This suggests cautious optimism about the ability of some individuals with mental illness, admittedly those already online, to access and use the Internet to better their lives and enhance their freedom of choice as well as that of others with this disability. Hopefully, others will explore these issues in subsequent surveys, so that information technology can be more readily available to mental health stakeholders who wish to use it. Since technology is shaped by its users, increasing the diversity of the Internet's online population has the potential to reshape information technology in ways that enhance its value to people with disabilities.

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*Funded by Cooperative Agreement # H133B000700 from the National Institute on Disability and Rehabilitation Research, U.S. Department of Education, and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of any federal agency.

**Please direct correspondence to:

Judith A. Cook, Ph.D., Center on Mental Health Services Research and Policy, Department of Psychiatry, University of Illinois at Chicago, 104 S. Michigan Avenue, Suite 900, Chicago, IL 60603, USA. Email: cook@ripco.com, Tel: 312-422-8180 x19, Fax: 312-422-0740.