the internet and clinical psychology

8/13/2019 The Internet and Clinical Psychology

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Clinical Psychology Review, Vol. 21, No. 1, pp. 129136, 2001Copyright 2000 Elsevier Science Ltd.Printed in the USA. All rights reserved

0272-7358/01/$see front matter

PII S0272-7358(99)00043-4

129

THE INTERNET AND

CLINICAL PSYCHOLOGY:

A GENERAL REVIEW OF THE IMPLICATIONS

M. A. Smith

University of Toronto

C. Senior

Institute of Psychiatry and GKT School of Medicine

ABSTRACT.

The Internet has grown exponentially from its original conception and now takes

the form of a vast network of interconnected computers. It encompasses such a wide arena withinscience that its impact cannot be ignored. This article reviews some of the areas where the Internetis relevant to Clinical Psychology. Three main areas identified and expanded upon are (i) use ofthe Internet as a communication medium within this domain, (ii) teaching of the discipline, and(iii) use of the Internet as a tool for psychological research. Within these three areas, examples ofthe applicability of the Internet are discussed as well as its limitations. In summary, use of the In-ternet within the psychological domain has many advantages and as such should be embraced bythe clinical psychologist. 2000 Elsevier Science Ltd.

KEY WORDS.

Internet, Clinical psychology, Research.

EVERY SO OFTEN a technology emerges that has the power to radically alter society.The telephone and television are two recent examples of devices that society has in-corporated into the daily routine of life. These devices are so ubiquitous that theyhave become almost natural elements in our environment. The computer is anothertechnological device that has the same potential, particularly because of its impor-tance for the continued existence and successful functioning of the global communi-cations network known as the Internet.

The Internet may be the next technology widely adopted and incorporated into ev-eryday usage. Both television and the telephone are important technological devices

Correspondence should be addressed to Dr. C. Senior, The Depersonalisation Research Unit,Institute of Psychiatry, & GKT School of Medicine, 103 Denmark Hill, London SE5-8AZ UnitedKingdom. E-Mail: [email protected]


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130 M. A. Smith and C. Senior

in our daily lives and their impact are the subject of a broad range of research efforts.For example, influence of television content (e.g., violence and sex) on behavior hasbeen widely investigated (Williams, Zabrack, & Joy, 1982; see Paik & Comstock, 1994,for a review). Further, technology often alters how we perform the activities it is

meant to augment, for example, telephone conversations have a structure quite dif-ferent from other types of conversations (Goldthwaite, 1997a, 1997b). Hence, exam-ining the impact of the Internet on behavior should prove both instructive and cau-tionary.

The Internet has the potential to have as great an impact on society and human be-havior as the telephone and the television. Examining the effects of the Internet onclinical psychology as a discipline brings to the fore important issues; this article dis-cusses two of these issues. First, it explores the Internets influence on clinical psychol-ogy. The discussion focuses on developments of the Internet that serve to highlight ar-eas that will have a particular impact on clinical psychology as a discipline. We argue

that the Internet is a useful tool for all areas within the clinical psychologists domain;further, it is now possible to investigate issues that take advantage of the Internetsunique aspects.

These areas will be addressed by elaborating on avenues where the Internet hasmade a considerable impact on clinical psychology as a discipline. First, we discuss itsinfluence on academic communication. Second, we discuss its influence on how thediscipline can be taught, and finally, its influence on research.

COMMUNICATION

Communication among colleagues is a vital part of any discipline. Keeping in touchwith colleagues, editors, or students serves several valuable functions. It permits indi-viduals to learn about the most current therapeutic practice, organize collaborativeprojects, and disseminate findings to the scientific community.

Electronic mail (e-mail) is by far the most common form of communicating in thisarea, and its use is increasing. One reason for the prevalence of e-mail is its ease ofuse. For example, contacting colleagues in another time zone poses many problems.Prior to e-mail, specified times needed to be arranged (e.g., at conferences), thus in-creasing the expense and time it takes to complete any collaboration. E-mail allows in-formation to be sent instantaneously to a colleague who reads the message and re-sponds at the earliest convenience.

Another development is Video conferencing (e.g., CU-SeeMe). This technology(http://www.cuseeme.com) allows individuals to have both visual and auditory cues asan aid to communication (Massaro & Stork, 1997).

In many ways the Internet is becoming not just another means of communications,but the preferred means of communication for the psychologist (Allie, 1995; Levy,1995, for reviews). Whether it be for manuscript collaboration or grant writing, the In-ternet has become an invaluable resource (Levy & Ransdell, 1996). For instance, re-searchers wanting to initiate an investigation requiring an expensive resource, (e.g.,functional neuroimaging), who do not have local access to such equipment can ap-

proach a researcher at another institution and discuss possible collaborative efforts.Further, the expertise of individuals in many different fields who are rarely at thesame location can be used. The cost in both time and money of bringing different ap-proaches together can be prodigious. As the Internet continues to develop, on-line


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The Internet and Psychology 131

video conferencing should become a more efficient use of limited research resourcesand still achieve the same research goals.

Reviewing use of the Internet as a communications tool highlights importance ofcommunication among colleagues. Further, we suggest that taking advantage of the

expanding capacities of the Internet will make clinical practice more efficient, andmay even promote collaborative efforts among institutions and researchers. This pro-cess will strengthen clinical psychology, promoting higher quality, where ultimatelythe client will benefit.

EDUCATION

Academic staff are increasingly relying on Internet resources to supplement coursematerial. Lecture materials are being placed on-line as review notes, providing links to

relevant material and allowing students to hand in assignments over the Internet. Fur-ther, many introductory psychology texts provide on-line supplementary learning ma-terial (e.g., Allyn & Bacon: http://www.abacon.com/interactive). Student researchhas become easier as more academic journals provide on-line versions of journals.

A useful adjunct to course material is supplementary material that elaborates ontopics discussed in lectures. Providing links on a course web page, along with lecturenotes and discussion groups, allows academic staff and students to supplement anyclass material and ensure that notes are complete. For example, lecture notes on-linecan have definitions of terms or hypertext links to examples, and other research orrelevant articles (Duchastel, 1997).

By placing lecture notes on the World Wide Web (WWW) students can learn coursematerial while placing less emphasis on note taking. This allows students who are in-terested in the material to more fully comprehend the concepts outside the limita-tions of a lecture format, thereby allowing the lecturer to focus on broader issues.

Some universities are also instituting on-line end-of-year testing; reducing paper us-age and providing the examiner with a number of unique opportunities. First, it al-lows students and staff flexibility in terms of testing, for example, students may be al-lowed to take examinations at times of their choosing, within allocated time frames.Also, given that students have access to information unavailable to them in a rigid ex-amination setting, there would be an emphasis on conceptual learning rather thanrote memory. This reduces the emphasis on memorization and places it more on ap-plication of concepts to novel problems (Callear & King, 1997).

There are several considerations that must be addressed in the design of on-line ex-aminations. First, flexible examination scheduling decreases test validity. If studentstake the examination early in the allotted time window there is the possibility thatthey will convey information to other students. A device to counter this would be totake advantage of test questions provided by introductory psychology text publishers.For example, 100 questions could be identified for a database that addresses issuesraised in lecture and a number of these could be randomly selected to present to on-line students. Every student would receive a slightly different version of an examina-tion with little extra effort on the part of the instructor. Although this may increase

the initial workload, over time test reliability will increase. Second, the type of testingmust be quite different; factual questions become less important.

Another important development from the Internet is the increasing availability ofon-line academic journals, although this has been met with controversy (Laporte &


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Hibbitts, 1996). Further, universities are offering on-line search engines that allow stu-dents to search for abstracts and full articles on the Internet (e.g., Bath Informationand Data Service BIDS: http://www.bids.ac.uk/). However, the expense of main-taining electronic journals often results in a charge having to be levied (see, e.g.,

Walker, 1998). Currently, the University of Toronto has over 7,000 journals availableon-line. Most have only their most recent volumes, but over time more back issues arebeing translated into an electronic format. Students will soon have the opportunity toaccess scholarly journals on-line, regardless of their location.

RESEARCH

Another interesting avenue open to the clinical psychologist is the ability to conductresearch on the Internet. Many investigators are beginning to explore this possibilityand a considerable body of literature already exists (Schmidt, 1997). The Internet can

be used in parallel with traditional research methods as well as exploring issues thatare unique to the Internet. This section reviews the current Internet research litera-ture, outlines some new Internet features, and discusses their potential as researchtools. Internet research falls into three broad categories: resource locators, demo-graphic surveys, and empirical investigations.

Resource Locators

The scope covered within this type of publication group is large and covers many ar-eas. Neurosurgery (Phillips, 1996), Nursing Administration (Sparks, 1997), and Psychia-

try (Senior, Phillips, & David, 1997) are a few examples of articles that direct inter-ested parties to relevant sites of specialist information on the Internet. Anotherexample (Rosen & Petty, 1997) directs teachers of research methods to Internet sitesrelevant to psychologists. These sites include the Computers in Teaching Initiative(CTI) centre in the United Kingdom

http://www.york.ac.uk/inst/ctipsych

, and thehomesite of the American Psychological Society

http://www.psychologicalscience.org

(also see Appendix).

Demographic Surveys

An example of demographic survey studies can be seen with Georgia University Visu-alization Units World Wide Web surveys (GVU WWW). These surveys attempt to iden-tify the demographic characteristics of the Internet population (Kehoe & Pitkow,1996). Originally, these surveys used a basic Hypertext Markup Language (HTML) ona WWW site, but were quickly upgraded. In the second GVU WWW survey, Pitkow andRecker (1994) redesigned the existing survey format to incorporate new features suchas adaptive questioning, survey completion enforcement, and user selected log-in IDs.

Adaptive questioning employs a Common Gateway Interface (CGI) script. This fea-ture presents users with a second set of questions that are tailored to follow on fromtheir initial submission, thereby creating a survey that reflected ideal demographics.

Questions that the user did not complete in the first batch were returned with the fol-low-up set. This process continued until all of the questions in the survey had been an-swered; incomplete surveys were not accepted. Later surveys used Java and Javascript languages to incorporate an even more advanced adaptive questioning engine.


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This engine allows follow-up questions to be presented in a more naturalistic manner incontrast to earlier batch presentation of follow-up questions. The implementation ofuser-selected identification log-ins also allowed the researchers to identify users that re-sponded to later versions of the survey, permitting longitudinal investigations.

Another example of a demographic survey is Schiano (1997). Schiano passively solic-ited responses by placing a request alongside the log-in message in a multi-user domain(MUD) called LamdaMOO. Over the week-ling testing period 550 subjects submittedviable responses. MUDs are text-based virtual worlds which evolved from role-playinggames in the 1960s. One of the MUDs unique features worth investigating is ability ofusers to assume any identity or gender. Further, the communication conventions andrules among inhabitants of this MUD that developed over the course of its 5-year exist-ence (see Bruckman, 1994, and Turkle, 1995, for reviews) also provide useful informa-tion about interpersonal communication.

Both the GVU and the Schiano (1997) surveys used passive subject recruitment

techniques, the most successful recruitment technique available to date on the Inter-net. However, these recruitment techniques have weaknesses and limitations, and al-ternatives are clearly needed. Further, the surveys discussed explored only demo-graphic variables of on-line populations; they did not test experimental hypotheses.

Empirical Investigations

A number of contemporary studies explore the aspect of experimental validity withInternet-based research (Krantz, Ballard, & Scher, 1997; Senior, Phillips, Barnes, &David, 1999; Smith & Leigh, 1997). Krantz et al. (1997) investigated the response ratesof two different subject groups; one recruited from a university environment and theother from the WWW. Both subject groups were presented with a number of differ-ent-sized schematic images that represented the female body form and asked to ratethe attractiveness of each image. The correlation between the two data sets ap-proached 1.0, leading to the conclusion that subject responses were due to the samepsychological variables and that there was no effect of experimental medium.

Another approach to establishing the validity of the Internet as a research mediumwould be to replicate previously published research. Smith and Leigh (1997) repli-cated an existing paper and pen study on sexual fantasies (Ellis & Symons, 1990).On-line subjects were recruited by posting a message on the Usenet newsgroupsci.psychology.research; demographic variables were matched. Results from Smithand Leigh (1997) and Ellis and Symons (1990) were comparable, supporting the no-tion that the Internet is a viable research medium.

Smith and Leigh (1997) also addressed a methodological concern of subject anonym-ity and data validity from the Internet. They asked subjects to telnet to a captive ac-count. This meant that the recruitment notice to the newsgroup gave instructions onhow to access a secure account monitored by the researchers. It allowed the researchersto gather information on participants and ensured that each volunteer only participatedonce. While this procedure was complex, 72 participants volunteered, suggesting that thecaptive account technique is also a useful technique for conducting Internet research.

Senior et al. (1999) investigated the validity of Internet research a third way. They

replicated a subtest of an experiment by Keating, Segall, and Mazur (1977) using theWWW. Keating et al. (1977), using schematic faces, examined what cues lead to theperception of social dominance and found that lowered eyebrows were importantcues. Schematic faces are excellent stimuli to use on the WWW as they are less vulner-


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able to cultural variability that may occur in an international subject pool. They arealso less prone to distortions that may occur with a lack of computer monitor stan-dardization across the Internet, and use little computer memory. Therefore, even par-ticipants with slow modems could load the images relatively quickly. Further, Senior et

al. (1999) employed a different technique to recruit participants than those describedearlier. They established a WWW site containing the schematic faces. The site wasplaced on-line for a month with a large number of catch words, for example, onlineresearch, face perception, and face expression research, in the meta section ofthe HTML code. The meta header is a section of HTML code that is not seen by theuser but is used to index the website by search engines such as Yahoo or Altavista (e.g.,http://www.altavista.com/). This allowed Internet search engines to present the sitelink when any of these key words were used in a search. Because they did not activelysolicit subjects, unlike the studies describe earlier, this technique was termed passivenet sampling. Senior et al. (1999) recorded a hit rate of 726, of which 185 (25%) re-

mained to complete the study. No differences were found between the data collectedin this study and Keating et al. (1977), providing a third line of evidence to supportthe contention that the Internet is a viable medium to carry out scientific investigations.

The studies described above all provide evidence that data collected using the Inter-net has validity. However, other research does not place an emphasis on data valida-tion but test actual hypotheses. Stern and Faber (1997) conducted an electronic ver-sion of Stanley Milgrams lost letter study on attitudes and behavior. Milgram (1977)dropped envelopes addressed to different classes of organizations over a geographicalarea and measured the return rate. This served as a measure of the attitude towardsthese organizations. Similarly, Stern and Faber (1997) investigated both the attitudesof a college on-line population using e-mail containing information messages relevantto a college population and toward an American political party leader (Ross Perot).Unlike Milgram (1977), there was no significant difference between experimentaland control e-mail groups in either experiment. Analysis of the content of returned e-mails of the political leader experiment revealed that the majority of returned e-mailscontained messages that expressed negative attitudes toward the political candidate.These results were concomitant with opinion polls at the time.

Further, psychophysical investigations have started to be explored on the Internet.Jan Van Veen, Bulthoff, and Givaty (1998) report five psychophysical experiments thatwere carried out on-line. They conclude that the Internet is a valid medium for certainforms of psychophysical research. Studies that require few data for each subject or de-mand subject diversity are ideally suited for Internet research. They also conclude thatstudies that require precise controlling of timing contrast or resolution should not becarried out on the Internet. Investigators have also started to explore the possibilities ofconducting clinical research on the Internet. Indeed, the existence of on-line discussiongroups (e.g., The depersonalization discussion board: http://depersonalization.hypermart.net) suggests that access to individuals who suffer from certain disorders is rela-tively easy. Initial investigations have suggested that the Internet will prove to be a pro-ductive research medium in this area (Stones & Perry, 1997, 1998; Lambert et al., 2000).

CONCLUSION

In summary, while the influence of the Internet continues to grow both inside and out-side the discipline of clinical psychology, the scientist/practitioner can and should play arole on influencing how the Internet develops. There is no shortage of issues that need


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to be addressed and many are uniquely suited to being addressed by clinical psycholo-gists. Our article highlighted some of these areas and hopefully provoked thought inthose who perhaps thought that the Internet was not relevant to their area of study andtherefore could be ignored. While the evidence is still accumulating, early indications

suggest that this is not the case and ignoring the Internet could be a perilous endeavor.

Acknowledgment

We gratefully acknowledge the support of Professor A. S. David. C.Senior is supported by the Albert Ferrary Trust, Gibraltar.

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APPENDIX

We enclose a list of internet websites that will be of interest to the Clinical Psycholo-gist. Rather than make the list extensive we have opted to limit the list to sites that at-tempt to collect resources together. The short descriptions, where included, havebeen taken from the actual sites.

1. The Institute of Psychiatry

http://www.iop.kcl.ac.uk

This site contains many links to other psychiatric based internet sites.2. University of Bonn, Clinical Psychology Site

http://www.psychologie.uni-bonn.de/kap/links_20.htm

This page contains WWW resources for Clinical and Abnormal Psychology, Be-havioral Medicine, and Mental Health.

3. Dr Robert Sulers site at Rider University, NY

http://www.rider.edu/users/suler/tcp.html

This site is devoted to sharing ideas and resources for the teaching of clinicalpsychology, especially undergraduate courses on abnormal psychology, psycho-

therapy, group dynamics, psychological testing, and clinical components of in-troductory psychology.4. A Neuropsychology Homepage

http://www.tbidoc.com/

Devoted to the understanding of brain injury, and the neuropsychologists rolein identifying, proving, and treating brain injury.

5. The National Academy of Neuropsychology

http://nan.drexel.edu/

6. Neuropsychology Central

http://www.neuropsychologycentral.com

7. University of Miami, Otto Richter Library

http://www.library.miami.edu/netguides/psyheal.html8. Kings College London, Depersonalization Research Unit

http://www.iop.kcl.ac.uk/depersonalization

the internet and clinical psychology

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