Dr Sophie Dennard – Sussex Partnership NHS Foundation Trust
Last year I qualified as a Clinical Psychologist. As part of my clinical training, I was very fortunate to work alongside the AVATAR2 trial (Garety et al, 2021, https://www.avatartherapytrial.com/) which explored the use of avatars to help people with psychosis, who often hear voices. This work opened my eyes to and piqued my interest in the use of technology to provide mental health interventions. People with psychosis are now using smartphones at the same rate to the general population. In recognition of this, digital interventions have been developing for people with psychosis. These include interventions delivered through smartphone apps, websites, and wearable devices, or those delivered through the use of virtual reality and avatars. For example, SlowMo is a digital intervention delivered through a smartphone app which aims to help people with distressing thoughts and paranoia (Garety et al, 2021, http://slowmotherapy.co.uk/).

What did we hope to find out?
We were interested in finding out more about the experiences of people with psychosis when using digital interventions. We hoped that by doing so, we could use the information to improve digital interventions and make sure they best suit the needs of people with psychosis and are an accessible form of assessment and/or treatment.
How did we find this out?
We completed a systematic review of studies that had asked people with psychosis about their experiences of using digital intervention. In total we reviewed 19 studies and bought together participant experiences within six main themes. These are summarised below;
What did we find?
Theme 1: Content of digital intervention
Participants spoke of wanting to be able to tailor interventions to their specific needs. This tailoring could include customising the timing of notifications they received, or having space to write feedback. Participant also wanted the opportunity to have their information displayed in a visual form, such as in a table or graph, to see how symptoms may have changed over time.
Notifications and reminders were reported to be helpful in reminding participants to take their medication or to complete different tasks. However, these notifications could sometimes be inaccurate and cause frustration.
Participants enjoyed some aspects of the digital interventions, such as answering questions and those which had a positive, solution focused tone. Participants did find the variety and range of content could be limited and that it felt repetitive over time.
Theme 2: Relationship with technology
Participants who had less experience of technology found it harder to use the digital interventions, especially initially. This could be made easier if they received training in how to use the interventions. Some raised concerns about technology which could make them less likely to want to use it, such as feeling suspicious about using the technology in case they were being ‘monitored’. Although, for some, being ‘monitored’ created a feeling of safety and being looked out for.
A number of participants experienced a range of technical issues which they sometimes had to fix. This could cause frustration and lead to less motivation to continue using the technology.
Theme 3: Accessibility
Participants described how easily accessible the interventions were, with people being able to use them at all times of the day. Being able to access support at any time helped people to feel safer. For the intervention to be even more useful, having them integrated more into routine care services was reported to be important.
The interventions were felt to be particularly useful in supporting with cognitive/physical difficulties. Memory difficulties were spoken about in particular and having an easily accessible intervention meant that people did not have to rely so much on their memories.
It was however raised that it was important to be mindful of the needs of those with lower literacy levels or visual impairments to make the interventions as inclusive as possible.
Theme 4: Awareness and management of mental health
Digital interventions helped people to self-manage their mental health. They reported being better able to manage different symptoms as well as take their medication. Participants reported finding it harder to use an intervention if they were experiencing voices, social anxiety or internalised stigma.
The digital interventions helped participants to feel more in control which increased feelings of empowerment and confidence. Participants also said they had increased insight into their mental health and were better able to spot and prevent relapses.

Theme 5: Enhancing communication and relationships
The digital interventions helped participants to feel understood by therapists, researchers and others who use the interventions. This helped people to feel their experiences were normal and that they weren’t alone in their struggles. This then had an impact on feeling like they had increased connection with others, which helped to reducing feeling of isolation and loneliness.
Digital interventions were also highlighted as being helpful in facilitating communication with others, making it feel easier and less threatening to talk about different topics. Participants also felt that these interventions could help them talk more to their loved ones about their experiences.
Theme 6: Opportunity for reflection
Participants spoke of the interventions as providing a space to reflect on their mental health symptoms and look at them more objectively. This reflection also helped to provide new or different perspectives on recovery, and helped them to believe that recovery is possible.
So, what does all of this mean?
The results of this review show that the use of digital interventions for people with psychosis can have several benefits. They can provide an opportunity for creating better understanding and management of people’s mental health, better relationships with care providers and demonstrate that people are not alone in their experiences, which can help to reduce loneliness and stigma.
All of this feels like a positive step forward into the digital world. However, we need to ensure that future digital interventions take into consideration that owning an using a smartphone is not sufficient, and that people will often need support with developing knowledge, skills and confidence to get the most out of them. If people don’t get training and support in using digital interventions, then we may end up increasing difficulties in accessing future interventions.
To make digital interventions easy and interesting to use, they should be customisable and
have a variety of features, whilst keeping tasks simple. Researchers and clinicians also need to ensure that they are transparent about the privacy of digital interventions and where data goes. By doing this, hopefully concerns about technology can be reduced. It is exciting that digital interventions can be a beneficial and accessible form of treatment for those who wish to use them. However, we also must respect that receiving an intervention using technology may not be for everyone and ensure that there is choice available.
If you are interested in reading the full systematic review article, you can find it here:
A systematic review of users experiences of using digital interventions within psychosis: a thematic synthesis of qualitative research | Social Psychiatry and Psychiatric Epidemiology (springer.com)
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