The extent of the problem

About 58% of the world's population uses some form of social media (Chaffey Reference Chaffey2022). A German study reported that this number was about 48% among psychiatric in-patients (Kalckreuth Reference Kalckreuth, Trefflich and Rummel-Kluge2014), and it is likely to have increased since the study was conducted. With the popularity of sites such as TikTok and Instagram, especially among younger people (London School of Economics and Political Science 2017), it could be seen as inevitable that snapshots of life while detained on a psychiatric ward would make it onto the internet. And that may not necessarily be a bad thing. It could help show others what to expect. Showing the inside of psychiatric hospitals could also aid in dispelling myths about them, an area which has been improving in recent decades (Angermeyer Reference Angermeyer, van der Auwera and Carta2017). More importantly, it allows a community to come together and to provide peer support (Ali Reference Ali, Farrer and Gulliver2015), crossing many thousands of miles sometimes, that may not be available in the service at that time. Searching for ‘grippy socks’, or ‘grippy socks holiday’ will bring up many videos of patients from inside mental health wards or talking about their stay (grippy socks is a popular euphemism used to refer to a mental health admission, in relation to the slipper socks provided to in-patients). Patients locked in a hospital, often against their will, can be made to feel that they are not alone (Griffiths Reference Griffiths, Calear and Banfield2009, Reference Griffiths2017).

Unfortunately, as with most things, context is key. Patients taking videos or photos of their ward may have some level of control. For example, the individual making the recording will be able to pick which videos to release or not release. Staff may be able to intervene even. In contrast, streaming video is uploaded immediately.

Ideally, we would have no information or images uploaded to the internet without informed consent, as once information is online it can broadly be considered there forever (Cumbow Reference Cumbow2011). However, if we cannot stop this and a patient does upload footage, if they use their own account, we know where it has been uploaded and there are legal mechanisms for taking videos down that work better when we can identify the user (BrandYourself 2018).

Streaming: privacy and consent

Live streaming is a form of entertainment and communication that has rapidly gone from something unheard of to something increasingly popular (Krings Reference Krings2020). Live streaming, or ‘streaming’, involves broadcasting some sort of media in real time, typically while the presenter adds their own commentary and their audience interacts via typing in a chat room.

Becoming interested in this novel phenomenon I sought out streams uploaded by psychiatric patients. I used the search terms #grippysock, #psychward and #sectioned on TikTok and checked associated profiles and live streams going on at the time. Some of these were relatively uncontroversial, such as a Q&A from a current patient about their experience, which could be an insightful and educational tool for prospective patients and staff. However, I also came across streams of patients engaging in distressing and violent behaviour such as barricading themselves in their room, other patients shouting and arguing with staff and patients discussing self-harm in graphic detail.

With these live streams there is no control over what is being shown. By its nature as a live medium, the streams are a second by second account of events, being broadcast publicly to anyone watching and potentially recorded by any who wish to do so, regardless of what occurs. With some instances, such as a patient barricading themselves in their room, streams can show patients in compromising and embarrassing situations. Possible information governance issues may become even more complex as other parties, such as other patients, staff and relatives, become involved.

In particular, when patients on the ward begin to live stream the actions of another patient without their consent (either because the patient has not been asked or would not be deemed to have the capacity to give it), this would likely contravene information governance rules and a patient's right to privacy under the European Convention on Human Rights (Woogara Reference Woogara2001).

In the above scenario, a non-consenting third party could have their identity broadcast to an unknown audience, including disclosing, for example, that they have been admitted to a psychiatric hospital.

The role of the chat room

The other aspect of patients streaming their in-patient stay is the chat room. Streaming also includes a chat function for viewers to interact with the streamer. This is common and popular in the streaming world and a large reason for how people build followings. Streamers and their audience have a parasocial relationship in which the viewer feels an unreciprocated intimate connection to the streamer (Kabir Reference Kabirn.d.). This is similar to the relationship between a celebrity and their fans but, unlike celebrities, streamers interact with their followers through a chat function. This added level of intimacy is often what draws people to streamers as opposed to other forms of media (de Wit Reference de Wit, van der Kraan and Theeuwes2020). By streaming, the individual gets far more interaction on their social media accounts (Social Media Marketing & Management Dashboard 2020). I see no reason for this not to apply to mental health wards and have seen streamers commenting about an increase in followers while live. This action of receiving more interaction incentivises streamers to engage in this activity further (Shanikabrooks 2021). This creates a positive feedback loop where streaming gains streamers more followers, leading to streaming algorithms making the account appear to more people, which then causes even more followers and an even bigger audience for the streamer's content.

Chat rooms also allow the patient to communicate with others while in the midst of a potential crisis. For instance, in the example I witnessed where a patient had barricaded themselves in their room, there were several individuals in the chat who were supporting the patient's view and encouraging them to not acquiesce to the rules on the ward. This input seemed unlikely to help and in fact appeared to hamper efforts to de-escalate the situation. There were also others who asked which hospital and ward the patient was on so that they could call the ward staff. Actions like this may serve only to further complicate the situation and add workload to nursing staff in an already difficult situation. These viewers may also not know the context of the situation, as they would not have access to the information that the team does. This could lead to undue anger and aggression directed towards staff.

The final aspect to consider is the exposure of the patient themselves in these chats. Patients in the height of crisis may not be capacitous and are likely to be in a very vulnerable position. The nature of streaming involves such an individual being interacted with by a potentially large number of anonymous strangers. To illustrate this point, during my review of streams I witnessed a female patient whose chat included viewers’ comments about her body and urging her to undress further or making more overt sexual comments. Although this streamer was ignoring or rebuffing these comments, the risk of exploitation is self-evident.

What should clinicians do?

So, what's the answer to this? Honestly, I don't have a quick and easy solution, a policy to take blanket effect. But the first step is that we clinicians begin to understand this new phenomenon. The internet is a space, a ‘cyberspace’ (Koepsell Reference Koepsell and Rapaport1995), so different from a physical space, but a space nonetheless. And just as we review how a patient uses physical spaces in relation to their mental illness and capacity, we need also to consider how they are using cyberspace.

There are many potential positives to internet use and in the interest of least restrictive practice (Griffiths Reference Griffiths2012) we should not be restricting internet use without an identified need. We need to be proactive in our discussions of this topic and realise the importance of cyberspace in the lives of our patients, in particular younger patients for whom social media can be an integral part of their lives (ReachOut 2014). It would also be helpful for clinicians to familiarise themselves with social media, to better understand their patients and how social media can be used and can have an impact on their lives.