Clinical Psychology Review, Vol. 21, No. 1, pp. 129136, 2001 Copyright 2000 Elsevier Science Ltd.

. Printed in the USA. All rights reserved 0272-7358/01/$see front matter

PII S0272-7358(99)00043-4

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 within science that its impact cannot be ignored. This article reviews some of the areas where the Internet is relevant to Clinical Psychology. Three main areas identified and expanded upon are (i) use of the 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 of the applicability of the Internet are discussed as well as its limitations. In summary, use of the Internet within the psychological domain has many advantages and as such should be embraced by the 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 incorporated into the daily routine of life. These devices are so ubiquitous that they have become almost natural elements in our environment. The computer is another technological device that has the same potential, particularly because of its importance for the continued existence and successful functioning of the global communications network known as the Internet. The Internet may be the next technology widely adopted and incorporated into everyday 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 United Kingdom. E-Mail: c.senior@iop.kcl.ac.uk

129

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 has been 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 different from other types of conversations (Goldthwaite, 1997a, 1997b). Hence, examining the impact of the Internet on behavior should prove both instructive and cautionary. The Internet has the potential to have as great an impact on society and human behavior as the telephone and the television. Examining the effects of the Internet on clinical psychology as a discipline brings to the fore important issues; this article discusses two of these issues. First, it explores the Internets influence on clinical psychology. The discussion focuses on developments of the Internet that serve to highlight areas 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 Internets unique aspects. These areas will be addressed by elaborating on avenues where the Internet has made a considerable impact on clinical psychology as a discipline. First, we discuss its influence on academic communication. Second, we discuss its influence on how the discipline can be taught, and finally, its influence on research.

COMMUNICATION Communication among colleagues is a vital part of any discipline. Keeping in touch with colleagues, editors, or students serves several valuable functions. It permits individuals to learn about the most current therapeutic practice, organize collaborative projects, and disseminate findings to the scientific community. Electronic mail (e-mail) is by far the most common form of communicating in this area, and its use is increasing. One reason for the prevalence of e-mail is its ease of use. 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 increasing the expense and time it takes to complete any collaboration. E-mail allows information to be sent instantaneously to a colleague who reads the message and responds 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 as an 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 Internet has become an invaluable resource (Levy & Ransdell, 1996). For instance, researchers wanting to initiate an investigation requiring an expensive resource, (e.g., functional neuroimaging), who do not have local access to such equipment can approach a researcher at another institution and discuss possible collaborative efforts. Further, the expertise of individuals in many different fields who are rarely at the same location can be used. The cost in both time and money of bringing different approaches together can be prodigious. As the Internet continues to develop, on-line

The Internet and Psychology

131

video conferencing should become a more efficient use of limited research resources and still achieve the same research goals. Reviewing use of the Internet as a communications tool highlights importance of communication among colleagues. Further, we suggest that taking advantage of the expanding capacities of the Internet will make clinical practice more efficient, and may even promote collaborative efforts among institutions and researchers. This process will strengthen clinical psychology, promoting higher quality, where ultimately the client will benefit.

EDUCATION Academic staff are increasingly relying on Internet resources to supplement course material. 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. Further, many introductory psychology texts provide on-line supplementary learning material (e.g., Allyn & Bacon: http://www.abacon.com/interactive). Student research has become easier as more academic journals provide on-line versions of journals. A useful adjunct to course material is supplementary material that elaborates on topics discussed in lectures. Providing links on a course web page, along with lecture notes and discussion groups, allows academic staff and students to supplement any class material and ensure that notes are complete. For example, lecture notes on-line can have definitions of terms or hypertext links to examples, and other research or relevant articles (Duchastel, 1997). By placing lecture notes on the World Wide Web (WWW) students can learn course material while placing less emphasis on note taking. This allows students who are interested in the material to more fully comprehend the concepts outside the limitations 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 usage and providing the examiner with a number of unique opportunities. First, it allows students and staff flexibility in terms of testing, for example, students may be allowed 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 examination setting, there would be an emphasis on conceptual learning rather than rote memory. This reduces the emphasis on memorization and places it more on application of concepts to novel problems (Callear & King, 1997). There are several considerations that must be addressed in the design of on-line examinations. First, flexible examination scheduling decreases test validity. If students take the examination early in the allotted time window there is the possibility that they will convey information to other students. A device to counter this would be to take advantage of test questions provided by introductory psychology text publishers. For example, 100 questions could be identified for a database that addresses issues raised in lecture and a number of these could be randomly selected to present to online students. Every student would receive a slightly different version of an examination 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 testing must be quite different; factual questions become less important. Another important development from the Internet is the increasing availability of on-line academic journals, although this has been met with controversy (Laporte &

132

M. A. Smith and C. Senior

Hibbitts, 1996). Further, universities are offering on-line search engines that allow students to search for abstracts and full articles on the Internet (e.g., Bath Information and Data Service BIDS: http://www.bids.ac.uk/). However, the expense of maintaining 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 available on-line. Most have only their most recent volumes, but over time more back issues are being translated into an electronic format. Students will soon have the opportunity to access scholarly journals on-line, regardless of their location.

RESEARCH Another interesting avenue open to the clinical psychologist is the ability to conduct research on the Internet. Many investigators are beginning to explore this possibility and 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 that are unique to the Internet. This section reviews the current Internet research literature, outlines some new Internet features, and discusses their potential as research tools. Internet research falls into three broad categories: resource locators, demographic surveys, and empirical investigations.

Resource Locators
The scope covered within this type of publication group is large and covers many areas. Neurosurgery (Phillips, 1996), Nursing Administration (Sparks, 1997), and Psychiatry (Senior, Phillips, & David, 1997) are a few examples of articles that direct interested parties to relevant sites of specialist information on the Internet. Another example (Rosen & Petty, 1997) directs teachers of research methods to Internet sites relevant to psychologists. These sites include the Computers in Teaching Initiative (CTI) centre in the United Kingdom http://www.york.ac.uk/inst/ctipsych, and the homesite 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 Visualization Units World Wide Web surveys (GVU WWW). These surveys attempt to identify the demographic characteristics of the Internet population (Kehoe & Pitkow, 1996). Originally, these surveys used a basic Hypertext Markup Language (HTML) on a WWW site, but were quickly upgraded. In the second GVU WWW survey, Pitkow and Recker (1994) redesigned the existing survey format to incorporate new features such as adaptive questioning, survey completion enforcement, and user selected log-in IDs. Adaptive questioning employs a Common Gateway Interface (CGI) script. This feature presents users with a second set of questions that are tailored to follow on from their 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 follow-up set. This process continued until all of the questions in the survey had been answered; incomplete surveys were not accepted. Later surveys used Java and Java script languages to incorporate an even more advanced adaptive questioning engine.

The Internet and Psychology

133

This engine allows follow-up questions to be presented in a more naturalistic manner in contrast to earlier batch presentation of follow-up questions. The implementation of user-selected identification log-ins also allowed the researchers to identify users that responded to later versions of the survey, permitting longitudinal investigations. Another example of a demographic survey is Schiano (1997). Schiano passively solicited 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 submitted viable responses. MUDs are text-based virtual worlds which evolved from role-playing games in the 1960s. One of the MUDs unique features worth investigating is ability of users to assume any identity or gender. Further, the communication conventions and rules among inhabitants of this MUD that developed over the course of its 5-year existence (see Bruckman, 1994, and Turkle, 1995, for reviews) also provide useful information 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 Internet. However, these recruitment techniques have weaknesses and limitations, and alternatives are clearly needed. Further, the surveys discussed explored only demographic variables of on-line populations; they did not test experimental hypotheses.

Empirical Investigations
A number of contemporary studies explore the aspect of experimental validity with Internet-based research (Krantz, Ballard, & Scher, 1997; Senior, Phillips, Barnes, & David, 1999; Smith & Leigh, 1997). Krantz et al. (1997) investigated the response rates of two different subject groups; one recruited from a university environment and the other from the WWW. Both subject groups were presented with a number of different-sized schematic images that represented the female body form and asked to rate the attractiveness of each image. The correlation between the two data sets approached 1.0, leading to the conclusion that subject responses were due to the same psychological variables and that there was no effect of experimental medium. Another approach to establishing the validity of the Internet as a research medium would be to replicate previously published research. Smith and Leigh (1997) replicated an existing paper and pen study on sexual fantasies (Ellis & Symons, 1990). On-line subjects were recruited by posting a message on the Usenet newsgroup sci.psychology.research; demographic variables were matched. Results from Smith and Leigh (1997) and Ellis and Symons (1990) were comparable, supporting the notion that the Internet is a viable research medium. Smith and Leigh (1997) also addressed a methodological concern of subject anonymity and data validity from the Internet. They asked subjects to telnet to a captive account. This meant that the recruitment notice to the newsgroup gave instructions on how to access a secure account monitored by the researchers. It allowed the researchers to gather information on participants and ensured that each volunteer only participated once. While this procedure was complex, 72 participants volunteered, suggesting that the captive 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 the WWW. Keating et al. (1977), using schematic faces, examined what cues lead to the perception of social dominance and found that lowered eyebrows were important cues. Schematic faces are excellent stimuli to use on the WWW as they are less vulner-

134

M. A. Smith and C. Senior

able to cultural variability that may occur in an international subject pool. They are also less prone to distortions that may occur with a lack of computer monitor standardization across the Internet, and use little computer memory. Therefore, even participants with slow modems could load the images relatively quickly. Further, Senior et al. (1999) employed a different technique to recruit participants than those described earlier. They established a WWW site containing the schematic faces. The site was placed on-line for a month with a large number of catch words, for example, online research, face perception, and face expression research, in the meta section of the HTML code. The meta header is a section of HTML code that is not seen by the user 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 site link when any of these key words were used in a search. Because they did not actively solicit subjects, unlike the studies describe earlier, this technique was termed passive net sampling. Senior et al. (1999) recorded a hit rate of 726, of which 185 (25%) remained to complete the study. No differences were found between the data collected in this study and Keating et al. (1977), providing a third line of evidence to support the 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 Internet has validity. However, other research does not place an emphasis on data validation but test actual hypotheses. Stern and Faber (1997) conducted an electronic version of Stanley Milgrams lost letter study on attitudes and behavior. Milgram (1977) dropped envelopes addressed to different classes of organizations over a geographical area and measured the return rate. This served as a measure of the attitude towards these organizations. Similarly, Stern and Faber (1997) investigated both the attitudes of a college on-line population using e-mail containing information messages relevant to a college population and toward an American political party leader (Ross Perot). Unlike Milgram (1977), there was no significant difference between experimental and control e-mail groups in either experiment. Analysis of the content of returned emails of the political leader experiment revealed that the majority of returned e-mails contained 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 that were carried out on-line. They conclude that the Internet is a valid medium for certain forms of psychophysical research. Studies that require few data for each subject or demand subject diversity are ideally suited for Internet research. They also conclude that studies that require precise controlling of timing contrast or resolution should not be carried out on the Internet. Investigators have also started to explore the possibilities of conducting clinical research on the Internet. Indeed, the existence of on-line discussion groups (e.g., The depersonalization discussion board: http://depersonalization.hyper mart.net) suggests that access to individuals who suffer from certain disorders is relatively easy. Initial investigations have suggested that the Internet will prove to be a productive 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 outside the discipline of clinical psychology, the scientist/practitioner can and should play a role on influencing how the Internet develops. There is no shortage of issues that need

The Internet and Psychology

135

to be addressed and many are uniquely suited to being addressed by clinical psychologists. Our article highlighted some of these areas and hopefully provoked thought in those who perhaps thought that the Internet was not relevant to their area of study and therefore 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. AcknowledgmentWe gratefully acknowledge the support of Professor A. S. David. C. Senior is supported by the Albert Ferrary Trust, Gibraltar. REFERENCES
Allie, D. (1995). The Internet and research: Explanation and resources. The Journal of Mind and Behaviour, 16, 339368. Bruckman, A. (1994). Approaches to managing deviant behaviour in virtual communities [On-line]. Available: http://www.cc.gatech.edu/FAC/amy.bruckman/papers/index.html Callear, D., & King, T. (1997). Using computer-based tests for information science. Association for Learning Technology Journal, 5, 2731. Available: http://www.warwick.ac.uk/alt-E/alt-J/vol5no1/ Duchastel, P. (1997). A web-based model for university instruction. Journal of Educational Technology Systems, 25, 221228. Ellis, B., & Symons, D. (1990). Sex differences in sexual fantasies: An evolutionary psychological approach. Journal of Sex Research, 27, 527555. Goldthwaite, D. (1997a). Knowledge of pragmatic conversational structure. Journal of Psycholinguistic Research, 26, 497508. Goldthwaite, D. (1997b). Pragmatic structure in naturally occurring conversations for making appointments. Journal of Psycholinguistic Research, 26, 631640. Jan Van Veen, H., Bulthoff, H. & Givaty, G. (1998). Psychophysics using the Internet: An evaluation. Perception, S27, 179. Keating, C., Segall, M., & Mazur, A. (1977). Facial gestures which inuence the perception of status. Sociometry, 40, 374378. Kehoe, C., & Pitkow, J. (1996). Surveying the territory: GVUs ve WWW user surveys [On-line]. Available via anonymous FTP: www.cc.gatech.edu/gvu/user_surveys/papers Krantz, J., Ballard, J., & Scher, J. (1997). Comparing the results of laboratory and World Wide web samples on the determinants of female attractiveness. Behavior Research Methods, Instruments, and Computers, 29, 264269. Lambert, M. V., Senior, C., Phillips, M. L., & David, A. S. (2000). Depersonalization in cyberspace. The Journal of Nervous and Mental Disease, 188, 764771. Laporte, R., & Hibbitts, B. (1996). Rights, wrongs, and journals in the age of cyberspace. British Medical Journal, 313, 16091612. Levy, C. (1995). Mosaic and the information superhighway: A virtual tiger in your tank. Behavior, Research Methods, Instruments, and Computers, 27, 187192. Levy, C., & Ransdell, S. (1996). Editing a book on the World Wide Web with 29 collaborators in 8 countries in 10 months: A case in survival tactics. Behavior Research Methods, Instruments, and Computers, 2, 145148. Massaro, D., & Stork, C. (1997). Speech recognition and sensory integration. American Scientist, 869, 235244. Milgram, S. (1977). The individual in a social world. New York: McGraw-Hill. Paik, H., & Comstock, G. (1994). The effects of television violence on antisocial behaviour: A Meta-analysis. Communication Research, 21, 516546. Phillips, N. (1996). Neurosurgery and the Internet. British Journal of Neurosurgery, 10, 555558. Pitkow, J., & Recker, M. (1994). Using the Web as a survey tool: Results from the second WWW user survey. Journal of Computer Networks and ISDN Systems, 27, 106110. Rosen, E., & Petty, L. (1997). Using Internet resources in a research methods course. Behavior Research Methods, Instruments, and Computers, 29, 222227. Schiano, D. (1997). Convergent methodologies in cyber-psychology: A case study. Behavior Research Methods, Instruments, and Computers, 29, 270273. Schmidt, W. (1997). World-Wide Web survey research: Benets, potential problems and solutions. Behavior Research Methods, Instruments, and Computers, 29, 274279. Senior, C., Phillips, M., Barnes, J., & David A. (1999). An investigation into the perception of dominance

136

M. A. Smith and C. Senior

from schematic faces: A study using the World-Wide Web. Behavior Research Methods, Instruments, and Computers, 31, 341346. Senior, C., Phillips, M., & David A. (1997). Psychiatry and the WWW: Some implications. Psychiatric Bulletin, 21, 775778. Smith, M., & Leigh, B. (1997). Virtual subjects: Using the Internet as an alternative source of subjects and research environment. Behavior Research Methods, Instruments, and Computers, 29, 496505. Sparks, S. (1997). Using the Internet for nursing administration. Journal of Nursing Administration, 27, 1520. Stern, S., & Faber, J. (1997). The lost e-mail method: Milgrams lost letter technique in the age of the Internet. Behavior Research Methods, Instruments, and Computers, 29, 260263. Stones, A., & Perry, D. (1997). Survey questionnaire data on panic attacks gathered using the WWW. Depression and Anxiety, 6, 8687. Stones, A., & Perry D. (1998). Preliminary evaluation of the World Wide Web as a tool for data collection the area of panic research. Paper presented at the Computers in Psychology conference, University of York, England. Available: http://www.york.ac.uk/inst/ctipsych/CiP98/abst Turkle, S. (1995). Life on the screen: Identity in the age of the Internet. New York: Simon & Shuster. Walker, T. (1998). Free Internet access to traditional journals. American Scientist, 86, 463471. Williams, M., Zabrack, L., & Joy L. (1982). The portrayal of aggression on North American television. Journal of Applied Social Psychology, 12, 360380.

APPENDIX We enclose a list of internet websites that will be of interest to the Clinical Psychologist. Rather than make the list extensive we have opted to limit the list to sites that attempt to collect resources together. The short descriptions, where included, have been 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, Behavioral 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 clinical psychology, especially undergraduate courses on abnormal psychology, psychotherapy, group dynamics, psychological testing, and clinical components of introductory psychology. 4. A Neuropsychology Homepage http://www.tbidoc.com/ Devoted to the understanding of brain injury, and the neuropsychologists role in 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.html 8. Kings College London, Depersonalization Research Unit http://www.iop.kcl.ac.uk/depersonalization