4.1 Interviews
In this section, we report our qualitative results from the perspectives of our interviewees, who are psychologists and psychiatrists practicing in the KSA. Participants’ demographics are illustrated in Table
2 and Figure
2. We identified five themes:
(i) Current practices in adopting technology in Saudi mental healthcare, where we found that despite the high interest in digitalization in the KSA, therapeutic tools and procedures for screening, assessment, and treatment remain paper-based in practice and present privacy and stigma-related challenges, on the other hand, there is a growing support of virtual clinics;
(ii) Clinicians’ perception of publicly available mental health mobile apps, where we revealed limited awareness of these apps among our interviewees and weak adoption in practice, except for remote consultation apps;
(iii) Perspectives around technology-facilitated privacy and anonymity in remote consultation apps, where we found that these features enhanced service accessibility, especially among those who have been discouraged by family or experienced fear of stigma of seeking mental health services in person or through the healthcare system, and we further unveiled tensions between practical and professional perspectives around turning off the camera, seeing anonymous patients and mitigating stigma;
(iv) Concerns about possible challenges exacerbated by adopting technology in mental health care, such as doctor shopping behaviour, and clients’ expectation of instantaneous responses and immediate diagnosis;
(v) Design considerations for supporting integrating mobile apps into Saudi mental health care.4.1.1 Current Practices in Adopting Technology in Saudi Mental Healthcare.
Therapeutic tools remain paper-based. Despite the high penetration of smartphones in the general population, clinicians reported that therapeutic tools for screening, assessment, and treatment (e.g., assessment scales, CBT worksheets and exercises, etc.) remained paper-based in clinics. This extended to when these tools were given to patients for home self-report; for example, PR24 said: “We print papers for patients, that we want them to fill out at home, to record their thoughts, feelings, behaviours, etc., as homework, and we ask them to bring these papers to the next session." PR16 also mentioned that “Patients filled out the printed assessment scales and submitted them to clinicians during visits."
However, paper-based tools present privacy challenges. For instance, some patients expressed concern that, as their written notes were easily left exposed, they could be easily read by others. These concerns included privacy concerns about family members; PL11 said: “Many clients share their room with other family members and were afraid that someone may read their papers." PL11 also discussed stigma as a common barrier associated with using paper tools and mentioned “Part of the effective treatment is that clients record their thoughts or events immediately, capturing their intensity accurately. However, clients experienced the embarrassment of writing on paper in public or in front of others, if something happened." Fear of social stigma was also relevant within clinical settings, where patients were concerned about who might access or read their papers. PR16 described that “Some clients ask about who will scan their filled scales and ask me to do it myself. Sometimes, they resist the scanning if a nurse will do it." This concern was often rooted in a fear of social stigma where they might be recognised by any member of the clinic staff.
To mitigate reported issues with the paper-based approach, professionals noticed that many clients are using built-in smartphone apps, namely the Notes app, to record their thoughts and symptoms or document their CBT homework. The Notes app was seen to provide better confidentiality by being under their control. Specialists also mentioned using email for transferring documents and communicating with their clients. Overall, professionals appreciated digital capabilities in managing data privacy compared to paper-based approaches.
Adoption of technology to support virtual clinics. As a response to the COVID-19 pandemic, most healthcare facilities in the KSA were obliged to adopt technology to provide their services. Therefore, almost all of our clinicians have experience in virtual clinics to provide mental health teleconsultations. For instance, PL10 said: “Within the government facility where I work, we provide 3 types of sessions: face-to-face, audio consultations, and virtual video-based sessions through a mobile app founded by the facility." Interviewees reported that most of the provided teleconsultations were audio, based on clients’ requests.
4.1.2 Clinicians’ Perception of Publicly Available Mental Health Mobile Apps.
Nearly all clinicians were aware of available commercial apps providing online psychological consultations. For example, PL15 said
“Labayh is the most well-known platform in the Arab world, followed by Famcare and Estenarh," (see Section
4.2.3 for apps’ description). Furthermore, half of our participants reported providing their services via existing commercial apps. Except for online consultation apps, most clinicians reported a weak awareness of available mobile apps supporting their therapeutic practice with clients, such as assessment, tracking and meditation. For instance, PR19 said:
“Ummm.... I do not know what kind of apps are available to support mental health." Moreover, they lack knowledge about what kind of mental health apps their clients used themselves to manage their condition. PL9 said:
“I have never heard from my clients about apps they use."Most clinicians reported a lack of Arabic mental health apps for education, meditation and tracking. For instance, PL18 said: “The available online Arabic mental health information is very dry [scarce]!" For meditation, some interviewees discussed their practices if a client does not speak English. PL11 said: “I advise them to record our meditation session via their mobiles and use it later to practice meditation at home" and PL18 said: “I do not mention any meditation apps. I know it is a limitation!" Otherwise, if the client speaks English, a few clinicians reported recommending some popular English meditation/mindfulness apps. PL10 said: “I usually recommend my clients, who speak English well, use Headspace for meditation." For the CBT tasks, only one psychologist (PL11) mentioned adopting a CBT-based mobile app specifically created in Arabic. This psychologist was actively involved in the app’s development and used it as a tool to enhance their clinical practice with clients. For self-tracking tasks, some professionals discussed their reluctance towards digital self-tracking apps. They debated that digital tracking may increase the risk of anxiety, stress and obsession or trigger negative emotions such as guilt, disappointment, and frustration. For example, PL10 said: “It may increase anxiety among clients with perfectionism, paranoia or OCD symptoms due to feeling observed." Clinicians further criticise the perceived objectiveness of passive digital tracking since contextual information and personal interpretations were not captured. PL18 mentioned that “Individuals want objectivity; [but] actually you do not need objectiveness! For example, if you are tired, the last thing you need is a smart tracker telling you that you are ready to face your day!" Such subjective data is crucial to understanding the context behind the numbers and reducing the possibility of misinterpretation. For example, when assessing a client’s sleep, specialists wanted to know any sleep-related data highlighting the effect of circumstantial causes and sleep hygiene on sleep quality. On the other hand, other clinicians believe that self-tracking apps could be adopted to increase client self-awareness and adherence and encourage them to perform activities.
4.1.3 Perspectives around Technology-Facilitated Privacy and Anonymity in Remote Consultation Apps.
Maintaining privacy. Clinicians discussed the advantage of privacy facilitated by technology in supporting seeking mental health help in Saudi society. For instance, PR20 said
“Individuals, especially women, who experience family resistance to therapy benefited from remote services as they can receive mental care privately at home, without anyone knowing about it." PL15 further mentioned that
“I receive many online appointments from clients at night when their families are asleep, as they don’t want them to know about seeing a therapist," and
“Some women clients told me if someone walks in on us talking, pretend to be my friend, not my therapist." Professionals also reported that most of their clients maintained a degree of privacy by keeping their cameras off during online sessions. For instance, PL11 mentioned that
“Almost all of my women clients do not turn on their cameras." Professionals’ attitudes regarding clients’ behaviour of keeping their cameras off varied. Some professionals perceived this as a challenge to the effective examination and building a therapeutic alliance with clients. For instance, PR20 said:
“It is supposed to be visual, but most clients refuse to turn on the camera. Non-visual consultation affects the examination process." PL23 also mentioned that
“Keeping the camera off is related somehow to Saudi social norms, and it is a common behaviour online, but it could hinder the therapeutic alliance." Accordingly, some professionals limited their services to visual sessions only. PR16 said
“If clients insist on keeping their cameras off, I usually apologize, refund and ask them to see another clinician instead. Even though some of the women clients, wear the Niqab 1 before turning on the camera, at least I can see who is behind the screen and notice their reactions." A clinician (PL11) further suggested that
“Turning on the camera during the session should be mandatory." On the other hand, some professionals prioritized the importance of supporting service accessibility in the current time over service quality. PR19 discussed
“Stigma still exists; We are keen to improve the situation gradually. At the current time, we should be careful not to add more obstacles like obligating clients to turn on their cameras for better service. We hardly reached them and adding more obstacles may take us a step back." The clinicians’ attitudes toward keeping their cameras on from their sides were also discussed. Most clinicians mention that they usually keep their cameras on and encourage their clients to do the same, while others reported that they themselves prefer to provide non-visual sessions. For instance, PR19 said
“It is more convenient, you know I do not have to wear a hijab 2 when my camera is off." To maintain service quality, a psychologist (PL23) further suggested that
“Clinicians should be obligated to turn on their cameras while making it optional for clients. This is not charity; this is a paid service and should be professional!" Maintaining anonymity. Clinicians also discussed the remarkable role of implementing anonymity within commercial apps in supporting seeking psychological help within Saudi society. PL15 said “I was not expecting that, but I have seen a massive turnout for such apps." PR20 also mentioned that “It helped a lot of individuals to seek mental healthcare as a lot of them have concerns about visiting psychiatric clinics." PL15 also discussed the advantage of anonymity for some Saudi individuals as “It helps some people to talk freely about sensitive or highly stigmatized problems that are not aligned with the religion or culture." Professionals had diverse perceptions regarding seeing anonymous clients. Some clinicians discussed the possible adverse effects of anonymity on the treatment process, therapeutic alliance and stigma. They expressed their concerns about seeing anonymized clients as they tend to hide basic information to protect their identities, such as marital status, education level, occupation, etc. Professionals think this behaviour could negatively affect the treatment process, and therefore, they do not prefer to see anonymized clients. PR22 said “an anonymous client was talking for 45 mins. about her case and hiding every identifiable information to protect her identity. At the end of the session, she provided some essential basic information that I usually find in the patient’s file in a different scenario." PR20 further expressed concerns about anonymity hindering building therapeutic alliance: “Transparency, starting from the client’s real name and background, usually helps in breaking the boundaries." Moreover, a psychiatrist (PR16) stated that they do not accept anonymous clients due to ethical concerns. On the other hand, some clinicians acknowledged the challenges introduced by anonymity but prioritized responding to the current mental health crises by supporting service accessibility at the current time. PR20 said “Currently, we have a documented problem in the KSA where 86% of people who are in need of psychological care do not seek treatment. Would we think about the consequence of anonymity in the long term?! We should now focus on supporting people to seek treatment. We can address the consequence of anonymity on the therapeutic alliance and stigma after a while after things are resolved."
Views on Stigma. Clinicians argued about the impact of anonymity, facilitated by commercial apps, on mitigating the stigma associated with mental disorders. Some professionals noticed that the ability to be anonymous considerably encouraged Saudi individuals to seek help as such apps helped to mitigate internal or self-stigma. However, they expressed their concerns about anonymity inadvertently reinforcing the stigma around mental illness in general. PR22 mentioned that “Based on my observation, such apps helped to reduce self-stigma. However, they may have a negative impact on the public and structured stigma." For instance, PR22 further explained that “By marketing such apps reduce stigma is in itself reinforcing stigma. They claim to provide a less stigmatizing platform, which in turn indicates that other means such as clinics have a higher level of stigma." PR16 also said “Anonymity implies that there is an actual big issue around mental illness and you should hide it. It exacerbates the stigma!" On the other hand, some professionals believed that by supporting service accessibility, the stigma would be mitigated over time, as they noticed that clients who perceived the benefit of treatment via these commercial apps encouraged their family and friends to seek help.
4.1.4 Concerns about Possible Challenges Exacerbated by Adopting Technology in Mental Health Care.
Doctor shopping behaviour. Some professionals expressed concerns exacerbated by technology as some clients on online private platforms simultaneously see several professionals during the same period, sometimes on the same day, for the treatment of the same problem without any communication between these specialists. Clinicians commented that while this phenomenon of visiting multiple doctors for the same complaint is seen in practice and could be a part of clients’ symptoms or personalities, it is easier to be noticed and controlled in traditional clinics and harder for clients to continue doing it. However, in technology, it is only one click to see another clinician, especially in online commercial platforms. For instance, PR22 said “Clients were trying many specialists as if they were wandering between shops and stores; they were happy to hear about this and did not like that, to the extent that there was a client who called me after seeing another therapist just an hour before me in the same app." Professionals stated that this notable technology-facilitated pattern of frequent changes in clinicians without a professional referral adversely affects both sides, clients and clinicians. It hinders therapeutic alliance and clients’ adherence to the treatment plan resulting in poor outcomes. Moreover, the practice of seeing clients mostly for one time and losing connection with them has negatively affected some professionals’ experience and their service quality with existing commercial platforms. PR22 said “Even for me as a clinician, I was concerned during the session as I have limited time, around 30 mins., and probably I will not see these clients again based on my previous experience. So, sessions turn on providing them with as much as possible of general one-size advice before the end of our first and last session! This could adversely affect the psychotherapy outcomes and thus its image in society."
Expectation of instantaneous responses and immediate diagnosis. Professionals noticed that clients on online platforms expect instantaneous services and immediate responses. Clinicians also discussed common expectations from their online clients that one session is sufficient for a diagnosis and treatment plan. PL18 said “Maybe when we say e-consultation compared to consultation, we lost the human in between. I mean, when we see e (for electronic), we assume that there is an instantaneous service. Clients when seeking online services expect that everything will be provided instantaneously including the diagnosis!" PL23 also mentioned that “I have noticed that if I am late even for some minutes, they easily get upset and start texting me! I have not noticed this in the traditional clinic, and I do not know why this occurs online. Do they assume that I am available since the services are provided on mobiles?"
4.1.5 Design Considerations for Supporting Integrating Mobile Apps into Saudi Mental Health Care.
Supporting access control, data confidentiality and interoperability. Empowering clients to control access to their collected data and support sharing them confidentially with their clinicians was highlighted by clinicians. PL9 said: “Suppose there is a shared platform that my clients and I could access, based on clients’ access permissions, to review their documentation. In other words, from the client’s perspective, I do choose what I share with clinicians for the period I want." Interoperability requirement was also emphasized to overcome the challenges of data accessibility and integration into clinical systems. PL15 said “Having the needed tools in one app will improve the effectiveness of our online experience." A psychiatrist (PR19) further suggested adding caregivers and family members to the app where they can provide their recorded data and insights related to the client’s case directly and confidentially to the clinician. PR19 said: “In my clinic, sometimes families who did not want to talk in front of clients wrote their notes on paper and handled them to me during the session. So, I think supporting the ability to involve a family member in monitoring apps is helpful."
Personalization and considering individuals’ preferences and professionals’ recommendations. Professionals valued considering individuals’ preferences, supporting customization and providing a variety of features and options. For example, PL18 said: “No matter which tool they use. If it works for them, it works for me." In addition, some specialists highlighted leveraging smart devices’ capabilities such as notifications and reminders to provide tailored services and support clients’ engagement. They stated that such alerts could help clients maintain their daily routines and increase adherence to treatment practices. Clinicians also explained the importance of taking into account individuals’ differences and clinicians’ expertise while designing mental health mobile apps to maximize effectiveness and reduce potential harm to clients. For instance, professionals advised supporting flexibility while determining individuals’ goals and avoiding fixed numeric targets (e.g., a specified number of daily steps) to mitigate potential negative consequences on clients when they fail to meet these goals exactly.