Remaining on course,online: Reflections and recommendations on more effective psychiatrist participation in online chat forums in the context of social media dynamics

Abstract

Objective

To provide a synthesis of psychiatrist experience, online resources, and peer-reviewed literature to document benefits and challenges, and thus derive recommendations on participating in professional psychiatrist online chat forums.

Conclusions

Psychiatrists should carefully consider and curate their participation in online chat forums. Convivial discourse, including shared interests, knowledge, and skills are benefits. However, social media dynamics influence online roles and behaviour. There is a performative aspect to chat forums and social media, through depiction of a participant’s persona, which can be understood through social avatar theory. Even on well-moderated chat forums, there remain the risks of subtle forms of negative social media roles and behaviour (e.g. cyberbullying, online abuse, and trolling). Furthermore, there are potential risks to professional identity and reputation from posting material as well as others commenting upon psychiatrists’ posts. A single unprofessional post can have a devastating impact on reputation. There are also opportunity costs from the time, attentional and emotional costs of following a forum, which can also lead to harms from anxiety and depression due to excessive social media use. We provide practical recommendations on e-professionalism for more effective participation online.

Especially during the pandemic, psychiatrists and many healthcare workers communicated via social media to connect and provide support to peers. Kindred spirits offer support and affirmation, but social media dynamics are also divisive, prompting engagement through conflict and negative emotions. This paper reflects on the experience of participation in psychiatrist chat forums, as well as referencing the evidence-base on healthcare worker social media use, where available, to derive practical recommendations for psychiatrists wishing to participate in online forums. The described experiences reflect on, but are not specific to, any psychiatrist online chat forums, and we are not discussing social media that interfaces with the public (which warrants a separate paper).

Challenges of online chat forums for psychiatrists

One of the main challenges arises from both personal identity and signalling of achievements to peers that one may not know professionally, introducing a performative identity element online. ¹ For example, a participant may publicise their views on a certain topic that they espouse, or quote a Web site or paper that they have authored. A participant’s use of social media therefore often involves the self-presentation of favourable information. ² Through iterative social media feedback, this creates a ‘social avatar’ which comprises the best aspects of the participant’s persona. ² Online, there is elision of the real gap between the social avatar and the actual substance and complexity, ‘warts and all’, of the participant’s persona. ² Additionally, there is potential one-upmanship in performative displays of identity ¹ from participants, as well as ineffective forms of interaction, such as humble-bragging which involves dissimulated or disguised bragging, which can lead to negative responses. ³ For example, a participant may over-effusively extol the financial success of their private outpatient clinic, in a way that may be perceived as humble-bragging. The creation of a social avatar should therefore be a carefully considered process, ² especially for psychiatrists. As a hallmark of mental health, the harmonious integration of the social avatar with offline, real-world aspects of personality should be an essential consideration for any person interacting via social media, ² including psychiatrists.

While forum moderation may prevent cyber-bullying in the form of direct threats or personal abuse, ⁴ more subtle forms of harassment can slip through, such as disguised trolling. Trolling is characterised as a social media interaction when someone deliberately tries to upset others online, and can lead to a ‘pile on’, where further participants join in an offensive attack of posts. ⁵ For example, participants may question participants on controversial topics (e.g. therapeutic use of hallucinogens) and then proceed to criticise other participants’ responses if they differed from their own views. Repetitive questioning can also occur on controversial topics. Such behaviour can lead to trolling, which is a subset of cyber-bullying and harassment in which victims are often unable to identify their experiences as abuse, resulting in shame and confusion. ⁶ Participants can use aggressive and repetitive questioning of other’s views and comment on the personal characteristics of candidates, such as their job roles. Moderators have issued guidance that psychiatrists on some forums were requested not to directly message any other participants in private chats, ostensibly in response to complaints about such actions.

Social avatar theory can help in understanding the motivations of the above negative online behaviours, which may arise from negative aspects of online persona such as disinhibition and dissociation.^2,7,8 Online forums may be considered an extension of the participant’s intra-psychic world, leading to interactions that may contribute to acting out, projection, and transference.^2,9 Through invidious online social comparison, a participant’s social avatar and the discrepancy from the real-world persona may contribute to negative emotions. ² Such negative emotional states may include dissatisfaction, envy, jealousy, and anger. ² The consequences of online social comparison, criticism, cyber-bullying, and harassment include heightened stress levels, anxiety, and depression. ⁶ These remain risks for psychiatrists in online forums due to the nature of the interactions.

Professionalism on online chat forums, online and digital communication

Even for psychiatrist-only forums, there remain professional risks as chat posts can easily be reposted to other social media or otherwise online. ¹⁰

Recent developments in healthcare workforce policy and practice have included attention to what is termed ‘e-professionalism’, that is, maintenance of healthcare worker professional ethics, standards of performance, and behaviour in online and digital communication. ¹¹ A recent scoping review has identified benefits as well as potential harms from health professional use of online communication. ¹¹ The benefits include opportunities for professional networking and collaboration; health professional education and training; patient and carer education; and health promotion. ¹¹ Peers can connect on the basis of their professional interests and network. Matters of mental health policy and practice, funding, and outcomes can be discussed.

There are potential pitfalls and dangers of online forum communication, mainly in the form of the perception of unprofessional behaviour, as well as legal issues such as defamation and disciplinary action for egregious unprofessional conduct. ¹¹

The RANZCP has issued guidance on psychiatrist use of social media and online presence, and perhaps the most apt advice is; ‘Psychiatrists who choose to utilise social media should do so in a professional manner and should refrain from making any comments that they would not make in a personal or professional capacity’. ¹² There is also the relevant warning that reposted views of a psychiatrist might involve ‘Expression of clear political or religious views that become known broadly will inevitably change the nature of the doctor-patient interaction’. ¹³

Recommendations for more effective participation in online chat forums

This paper focuses on psychiatrist participation in online chat forums. Based on the synthesis of our experiences, online resources cited above, and the peer-reviewed literature on healthcare worker social media use we recommend the following guidelines:

1. Be always mindful that you are developing a social avatar, which is a performative online version of your persona that should be harmonious and integrated with your offline, real-world self. ²

2. Consider to whom you are writing, is it in response to another participant, or if you are in another role, moderator, candidate etc. Consider the presentation of your online ‘social avatar’ as a broadcast of your persona ² and professional views.

3. Write under the assumption that your post will be made publicly available:

a. Is it a true and accurate reflection of your considered professional views? ¹³

b. Are you comfortable with your peers, patients, employers, family, and friends seeing this expression of your views and the manner in which you express them? ¹³

c. Could your post be construed as cyberbullying or trolling?

4. Use a desktop device and larger screen to read the chat properly and compose your response using a keyboard, including accessing spelling, and previewing your post. This can contribute to presentation of a professional social avatar that is harmonious with your offline persona.^2,13

a. In composing, consider the Chinese proverb: ‘Even four horses and a chariot cannot draw back bad words’.

5. Do not engage in exchanges of cyberbullying and trolling, as they result from the online disinhibition effect. ⁷ If you encounter a trolling post, resist the urge to respond, ⁵ as the intent is to engage you in an emotional response that can explode into a ‘pile-on’ or adversarial ‘flame-war’ in which participants propel negative comments about each other. Such negative interactions may be driven by both disinhibition ⁷ and the expression of different personality types online. ⁹

6. Collect evidence of the online chat post if offensive, trolling, or bullying to intercede with the moderator in the first instance and consider a formal complaint to the forum venue if needed.^4,5

7. If you are distressed by the online chat forum, exit the chat and seek peer and family support, as well as professional healthcare as needed.^4,5

8. Even if you are not overtly affected by the chat forum, confrontational interactions of participants and the forum discord can lead to negative emotions, ² as does high levels of exposure to social media. ¹⁴

Conclusions

Social media use by psychiatrists, such as online chat forums, can have many benefits for collegiality and communication. For participants who do not know each other professionally, there may be a necessarily greater degree of performative identity display for participants, explained by social avatar theory which describes the self-presentation of the best aspects of a participant’s personality.^2,8 Social avatar theory can also explain challenges such as trolling, and subtler forms of harassment, such as repetitive questioning and criticism, due to online disinhibition and personality expression.^2,7,9 As with all clinical interactions, psychiatrists must always consider that every word written, and phrase uttered, could potentially be on display to the patients and the public indefinitely. More light, and less heat, makes for better communication and a more informed professional community and polity.