The UK has an estimated 62 million monthly internet users (Statista, 2020), with smartphones now providing access to the internet at our fingertips. However, as our access to technology and the internet becomes easier, the levels of digital risk we are exposed to, along with our chances of harm, gets bigger. Previous studies have explored the risks associated with digital and online use, including harassment, grooming and cyberbullying (Coble, 2020), and has found these to be associated with increased self-harm, depression, anxiety, suicidality, and drug and alcohol misuse (Elgar et al., 2014; Daine et al., 2013, John et al., 2019).
This influx of digital risk is therefore creating a complex challenge for psychiatrists and other mental health professionals. Individuals with mental health problems are less likely to have the resources to counter online risks, and have therefore been found to be more vulnerable to risks such as pro-suicide or other harmful websites (Durkee, Hadlaczky, Westerlund & Carli, 2011), cyber-scams and inappropriate content (El Asam & Katz, 2018).
Despite these research findings, an accepted protocol is yet to exist for assessing digital risk in mental healthcare, along with no research exploring the practice of digital risk assessments amongst mental health professionals. Therefore, this research was conducted to fill this gap, by exploring the experiences, views, and understanding of digital risk, and digital risk practices among UK psychiatry trainees.
The authors carried out a sequential mixed-methods study, involving a cross-sectional survey followed by a series of focus groups with London-based psychiatry trainees.
A survey was developed by the authors using a three-stage process:
- A literature review on digital risk was conducted and a survey was drafted with input from clinicians and specialists from the NHS
- The draft survey was presented to the London Digital Safety Network (leading experts in digital risks in psychiatry) and revised in response to feedback
- The survey was then piloted in two stages with trainee psychiatrists (first pilot) and mental health professionals (second pilot) and further amended based on feedback.
The final survey included questions about:
- Previous experience and training in digital risk
- Demographic information
- Occupational history (including training grade)
- Duration of psychiatry experience
- Psychiatry speciality (i.e. working age adults, older adults, children and adolescents (CAMHS), forensic patients or other)
- Frequency of the trainee’s own internet use and ownership of technology.
The survey was conducted at a conference in which London-based psychiatry trainees were expected to attend, who were provided with both a paper and web-based copy.
Following completion and analysis of the survey, three semi-structured focus groups were carried out with psychiatry trainees based within London (see below). Participants were purposively sampled (by stage of training and speciality) to ensure a broad range of experiences and views were collected.
- Focus group 1: Core trainees (1-3 years experience)
- Focus group 2: Higher trainees in general adult psychiatry (>4 years experience)
- Focus group 3: Higher trainees in CAMHS (>4 years experience with children under 18 years).
A semi-structured topic guide was developed using the results from the cross-sectional survey and discussions with the London Digital Safety Network. The focus groups were analysed using thematic analysis by two authors, with disagreements discussed and resolved within the wider team.
Overall, results from 113 trainees were included in the analysis. The sample had high levels of digital literacy, with 92% reporting to own a smartphone. The main findings are detailed below.
- Over half of the sample reported previously treating patients exposed to digital risks, yet 23% reported not considering the impact of a patient’s digital life on their mental health
- CAMHS trainees were more likely to have treated a patient affected by digital risk (77% vs 44%) yet were not more likely to ask about a patient’s digital life. However, when they did ask, they were more likely to ask about specific risks (such as risky/sexual behaviour on the Internet or risky websites) compared to other trainees
- Regarding digital risk questioning, most commonly trainees asked patients if they had sought information online about their mental health, or if they had purchased medication/drugs online
- Over 90% of the sample had received no training in digital risk assessments, with 70% expressing a desire for training
- Approximately 60% did not feeling competent in assessing online risk behaviour, with only 5% of trainees reporting their current risk assessment document to contain a prompt about internet use
- Whilst those who had received training were more likely to see themselves as competent to assess online risk, these trainees were not more likely to ask about the impact of a patient’s digital life.
Eleven trainees participated in three focus groups. All were between the ages of 25-35, were from a range of ethnic backgrounds (all UK-born), and mostly female. Overall, two themes were identified, (1) Barriers to assessment and management, and (2) Double-edged sword.
Barriers to assessment and management
The first theme identified the various barriers in assessing digital risk, which ultimately meant that questions about digital risks were rarely asked during assessments. A lot of trainees felt their lack of first-hand knowledge or their fear of appearing ‘out of touch’ impacted upon their confidence to ask questions. A lack of training in digital risk assessments was reported in all groups and all trainees reported wanting more formal support and guidance in this area. Surprisingly, the core trainees expressed the most anxiety around asking questions, even though they were the most digitally literate.
Trainees felt that their practice had not yet adapted to patients having a ‘third world’ online, with some CAMHS trainees concerned that patients might be more likely to share private information online. Therefore, a trade-off between respecting a patient’s privacy and assessing for digital risks was acknowledged, with differing attitudes reported about the ethics of searching for patients online to assess risk. Whilst some felt this was an invasion of privacy, others felt that looking up a patient online to assess their mental state was justified if the information was on a public domain.
The second theme identified the difficulty for the trainees in balancing the risks and benefits associated with their patients being online, worrying about their vulnerability. Trainee’s reported patient experiences of cyber-bullying after sharing their thoughts and feelings online (which was often made worse by the perpetrators anonymity), pressures of unachievable goals placed on them by social media (resulting in low self-esteem) and the use of risky websites and forums (such as pro-suicide or pro-anorexia websites). However, there were also clear benefits for patients online. The anonymity of being online often allowed patients to speak freely about their mental health and the curation of a life online allowed them to exist on the internet without judgment or stigma. Finally, the use of online peer support forums was reported to provide benefits to patients, particularly out of hours.
- Overall, this study presents the best available evidence to date looking at trainee psychiatrists’ experiences and views surrounding assessing and managing digital risk.
- Whilst the authors found relatively high levels of awareness surrounding online risks, many barriers and challenges were cited in assessing and managing these risks in routine clinical practice.
- There were varying levels of confidence and competence from the trainees in this study, with most seeing the value of training in this area.
Strengths and limitations
This study had various strengths:
- This is the first study to date exploring trainee psychiatrists’ attitudes towards digital risk and therefore begins to fill an important gap in the literature, which should lead to future research
- The research team was comprised of researchers from all different backgrounds to reduce bias and encourage personal reflexivity, which was further highlighted for the reader with their specialities outlined in the paper
- The thorough process of developing the quantitative survey included reviewing the literature, seeking input and feedback from specialists, revisions based on feedback and extensive piloting. This ensured its validity as much as possible
- The final version of the survey and topic guide for the focus groups were included at the end of the paper, allowing for transparency and replication of the research.
However, there were limitations:
- Despite the thorough process to ensure survey validity, the lack of any other published surveys meant the tool could not be validated
- Only London-based psychiatry trainees were included in this study, with a low response rate in the survey. Therefore, these findings cannot be generalised beyond this population
- There may have been a social desirability bias in the focus groups, due to colleagues participating together, which could have potentially censored the conversation
- Since the data collection for this research occurred between 2013-2016, the findings of this study might now be outdated. However, the authors argue that whilst digital literacy may have increased since then, it’s likely that digital risk has too
- Whilst the authors included a wide range of professional backgrounds, there were no lived experience representatives included and no evidence of lived experience groups or panels used in the creation of the survey or focus group topic guide.
Implications for practice
The findings from this study have important implications for mental health care going forward. It is paramount that mental health professionals and services can evolve quickly in line with the continuing technical revolution, however, judging by the findings in this study this is yet to be seen. Whilst there are published frameworks available focusing on web safety, digital risk has yet to be acknowledged by clinical and regulatory bodies. Therefore, the authors of this study are recommending that both the Royal College of Psychiatrists and Health Education England act on leading training on digital risk assessments and management in mental health training and services. The challenges posed by digital risks needs to be embedded within policies and procedures, to ensure those working in mental health services are both competent and confident in assessing and managing these risks.
Important next steps rest in more research being conducted. Replication of the current study both in the UK and abroad is crucial to help to fill a large gap in the literature. Research with psychiatrists and mental health professionals at all stages of their careers might also be useful, to understand more about how digital risks are assessed and managed in practice.
Whilst our lives are further consumed by technology, unless mental health services actively work to understand, assess, and manage digital risks, an entire ‘third world’ of a patient could potentially be missed.
Statement of interests
Aref-Adib, G., Landy, G., Eskinazi, M., Sommerlad, A., Morant, N., Johnson, S., … & Pitman, A. (2020). Assessing digital risk in psychiatric patients: Mixed methods study of psychiatry trainees’ experiences, views, and understanding (PDF). JMIR Mental Health, 7(7), e19008.
Coble, S. (2020). Facebook Crime Rises 19% as UK Tries to Police Social Media. [Last accessed 15.09.2020]
Daine, K., Hawton, K., Singaravelu, V., Stewart, A., Simkin, S., & Montgomery, P. (2013). The power of the web: A systematic review of studies of the influence of the internet on self-harm and suicide in young people (PDF). PLoS One, 8(10), e77555.
Durkee, T., Hadlaczky, G., Westerlund, M., Carli, V. (2011). Internet pathways in suicidality: A review of the evidence (Full Text). Int J Environ Res Public Health, 8(10), 3938-3952.
El Asam, A., & Katz, A. (2018). Vulnerable young people and their experience of online risks. Hum–Comput Interact, 33(4), 281-304. [Taylor & Francis Online Abstract]
Elgar, F.J., Napoletano, A., Saul, G., Dirks, M. A., Craig, W., Poteat, V.P., & Koenig, B. W. (2014). Cyberbullying victimization and mental health in adolescents and the moderating role of family dinners (PDF). JAMA Pediatr, 168(11), 1015-1022.
John, A., Glendenning, A. C., Marchant, A., Montgomery, P., Stewart, A., Wood, S., … & Hawton, K. (2019). Self-harm, suicidal behaviours, and cyberbullying in children and young people: systematic review (PDF). J Med Internet Res, 20(4), e129.
Statista (2020). Internet usage in the United Kingdom (UK)- Statistics and facts. [Last accessed on 15.09.2020]