Psychiatric nursing in a shrinking world: The impact and implications of the Internet and computer mediated communication on the field of psychiatric nursing practice, research and education.


By Richard Lakeman  © 2002



Within the last decade computer mediated communication (CMC) facilitated by the growth of the Internet has transformed the way many people relate to each other and their world. In a metaphorical but very real way the world has become a smaller place in which distance and time may be transcended and bridges between cultures are built at a keystroke. The rapid growth in this area of technology and the exponential growth of internet usage poses a challenge to traditional notions of identity and community which are central constructs in the theorising and practice of psychiatry, psychotherapy and psychiatric nursing. This paper considers the impact and implications that CMC might have on the field of psychiatric nursing education, practice and research.



It often happens, with regard to new inventions, that one part of the general public finds them useless and another part considers them to be impossible. When it becomes clear that the possibility and the usefulness can no longer be denied, most agree that the whole thing was fairly easy to discover and that they knew about it all along

Abraham Eldecrantz - Inventor of the Swedish Optical Telegraph (Jones, 1999)



Computer mediated communication (CMC), and the Internet in particular has transformed and will continue to transform the world we live in. Within a decade, the Internet has become a ubiquitous presence in the everyday life and discourse of ordinary people. The growth of Internet access has been prodigious, rising from an estimated 50 million accessing the Internet in 1996 to 542 million people in 2002 (Nua, 2002). One is hard pressed to discover any technological advance that has so rapidly been taken up by the population. Some of the implications and consequences of the growth of the Internet and CMC are obvious. For example, the world has become a smaller place, with the constraints of time, geography, and cost of communication between people being dramatically reduced. However, the specific impact of these changes on personal relationships, identity, notions of community and society remains relatively unexplored and uncertain.


CMC in human evolution

Until relatively recently the most formative social influences on peoples learning, development of identity and culture were others in the immediate geographical environment mediated through face-to-face (f2f) communication. Communications technologies have radically changed the dynamics of identity formation and altered the transmission and shaping of knowledge. Technologies such as the written word, the telephone, radio and television have radically altered the way we construct the world, our communities and ourselves.


As McLuhan (1964) famously observed, “The medium is the message”, and the message of any medium is the change of scale, pace or pattern it introduces into human relationships. The Internet will have a more profound impact on human evolution than other media as it provides a gateway to communicate, interact and share information quite like no other. Cyberspace provides a fluid context for communication, a space where different environments may be created and experienced, information shared, and identities explored. In practical terms cyberspace is open for social activities, commerce, building community networks, and political action. It is a space of possibilities both good and bad.


From a psychological perspective the Internet may be considered in a number of ways, although no one model can fully encapsulate it’s complexity.

Mantovani (2001) suggests three psychological models as lenses to view the Internet:

This paper will briefly explore these three models with respect to issues pertinent to mental health and psychiatric nursing.


Information foraging on the WWW

The Internet has become a vast repository of information. The Google Search Engine searches over 2 billion on-line documents accessible via the WWW and the number grows by the second. In 1996 a survey of the International Psychiatric Nursing E-mail List found that for many people the relative superficiality, impermanence and general lack of clinically useful information was an impediment to its usefulness (Lakeman, 1998). A follow-up survey in 1999 examining how people’s use had changed found that people had become more discerning, focused and sophisticated in their use of the Internet (Lakeman, 2000). People had adapted to both the increased quantity and were more selective of information of questionable quality. Today, almost every peer-reviewed journal and major database is available on the WWW. The problem is no longer the lack of relevant information but discerning what is relevant from what is not.


The Internet is largely beyond regulation and consequently, every conceivable type of information or disinformation may be found. This is a radical departure from traditional media that have been carefully controlled and censored. No longer are professionals the gatekeepers of information and consumers of health services may be better informed about issues than health professionals. Thus, the Internet may prove to be a tool of emancipation, enabling people to research and arrive at their own solutions to problems, and to make informed decisions about treatments.


The Internet provides health information accessible to those who might not otherwise seek or have professional help available. The results of a trial of an alcohol-screening site suggest that there is a sizable population seeking help on the Internet for drinking problems (Cloud & Peacock, 2001). Computer mediated screening for alcoholism has been found to be as reliable as f2f assessment (Bernadt, Daniels, Blizard, & Murray, 1989) and individuals have also been found to be more willing to reveal negatively sanctioned behaviors to a computer than to another person or on a questionnaire (Malcolm, Sturgis, Anton, & Williams, 1989). There is some evidence that treatment of depression with CBT may be effectively delivered by computer (Selmi, Klein, Greist, & Sorrell, 1990). Indeed a wide range of brief psychotherapies may be delivered by self-help manual or computer package (Marks, 2002). The Internet will prove to be a valuable self-help resource for increasing numbers of people.


Unfettered access to information may also pose problems. The Internet provides the opportunity to indulge every fetish, fantasy, and narcissistic tendency at leisure and with relative impunity. Pornography is thought to be the most sought after commodity on the Internet (Griffiths, 2000). Research examining 42 million search pages accessed by the most popular search engines between March 1999 and January 2001 revealed that “sex” was the most popular search term (Pastore, 2001). Indeed people search for "sex" more often than "games," "music," "travel," "jokes," "cars," "jobs," "weather" and "health" combined. However, it is worth noting that the top 50 search terms account for only 2.73 percent of all search term page views, reflecting the incredible diversity of people’s interests. Not surprisingly, hazards such as the exposure of children to pornography, addictions and compulsive behaviour associated with the Internet are emerging as problems for some people (Oravec, 2000).


There is a wealth of accessible health information on the net should people choose to search for it. In an experimental situation a small group were able to find answers to a health question on the Internet within 6 minutes (Eysenbach & Köhler, 2002). There does, however seem to be some concern about the quality of information on the Internet and energy has been invested in developing measures of information quality. Griffiths and Christensen (2000) reviewed 21 frequently accessed sites on depression and concluded that most contained useful information, but were of poor quality and did not cite scientific evidence for conclusions.


The following criteria have been suggested for judging the credibility and quality of a mental health WWW site (Morahan-Martin & Anderson, 2000):

These recommendations do not guarantee integrity. Gagliardi and Jadad (2002) found 48 rating instruments and awards for health related web sites, but none reported on inter-rater reliability or construct validity. Many ‘stamps of approval’ continued to appear on websites providing health information, even when the organisations providing endorsement no longer existed. Participants in focus groups said that when assessing the credibility of a website they primarily looked for the source, professional design, a scientific or official touch, language, and ease of use (Eysenbach & Köhler, 2002). However, when observed, no participants checked any disclaimers, or disclosure sections of web sites. Whilst a huge number of people use the Internet as their principle means of looking for information, very little is known about the processes they use to evaluate what they find.


Whether, or not the issue of quality of information is really a problem, or more of a problem than for other media is open to debate. A recent review found few reports of actual harm due to misinformation of health information on the web (Crocco, Villasis Keever, & Jadad, 2002). However, it is highly likely that harm from Internet usage is underreported. For example if one seeks information on support for ‘incest’, one is likely be directed to a pornographic site. A search for ‘anorexia’ will reveal a wealth of avenues for help and support, but also pro-anorexia sites that celebrate the condition and offer advice and guidance on how to deceive family and health professionals. This was brought to public attention in 2001 by Time magazine, and in response to the story most pro-anorexia yahoo sites were taken down within days (Reaves, 2001). This type of censorship (albeit motivated by commercial interests) is unlikely to stop the promulgation of unsavoury or inaccurate information on the Internet. As Winston Churches observed over 50 years ago, “A lie gets halfway around the world before the truth has a chance to get its pants on”. That time has become much quicker with the Internet.


One further germane example of health related information relates to suicide. One can readily find sites that provide detailed instructions and critiques of various methods of suicide according to lethality, speed, pain and how to leave a clean corpse. One such site provides a detailed transcript of an instructional video on how to kill oneself with industrial carbon monoxide, complete with costings. Jerry Hunt (Hunt, 1993), who suicided in 1993 states on the page, “I think I'd have to say: Don't go too soon, don't wait too long”. The newsgroup has it’s own web site which is a repository for suicide notes and pro-suicide messages. One page is a combined suicide note and reference on hanging (see: Steven who apparently has suicided states in his introduction:

Welcome, all of you. Whether you be suicidal folk, looking for a quick, sure, economical, and "painless" way to die, or are some conservative prick hoping to stifle my words. Perhaps you're just curious about hanging, perhaps you want to murder someone, be you one, or all, welcome. Disclaimer of the disclaimer: I could care less about lawsuits, and penalty of law, you know why? If you're reading this, I'm dead. Ha, ha, can't punish me!

In some instances sites incite people to suicide, and they may be sufficient to shift people from ambivalence to action. Baume, Rolfe and Clinton (1998, p.140) conclude that “...there is scope for nurses to develop Internet resources to counter the nihilism of those who use it celebrate suicide and encourage others to end their lives”.


The Internet as a communications and social-cultural medium

The greatest single determinant of behaviour on the Internet is the purpose, or intent of people that use it. From its conception communication has been the dominant purpose. As a communications tool the Internet provides a means to reach out and help people. According to a study on the impact of the terrorist attacks on media use, after the September 11 terrorist attacks, over 100 million American’s sent or received “I care” e-mail (Lebo & Wolpert, 2002). A huge number of people reach out and forge or maintain relationships and emotional bonds through e-mail and other Internet communication applications.


Communication occurs in different Internet environments that shape the behaviour of those that experience them (Riva & Galimberti, 2001). Applications include e-mail, e-mail lists, newsgroups, bulletin boards, real-time text, speech or video chatting, multi-user dungeons (MUDS) and meta-worlds. These environments emulate some aspects of more traditional modes of communication, e.g. f2f, telephony or letter writing but people relate to the environment and consequently each other quite differently. The greatest challenge for people relating using the Internet is not the technology but acclimatising to the shifts in expectations associated with new methods of communicating (Huang & Alessi, 1996).


Early research examining computer mediated communication (CMC) was largely undertaken in experimental conditions and suggested that CMC was impersonal, disinhibited, shallow and sometimes antisocial relative to f2f communication (Lakeman & Murray, 2000). Some theorists suggest that the fewer the communication channels available, the less attention will be paid to the speaker and the more impersonal the communication will become (Moody, 2001). In contrast, studies of real-life e-mail communities (Lakeman, 1998, 2000) suggest that CMC can be a rich communication medium and at times more inclusive than f2f communication. With e-mail people may enter into a dialogue without concern for the trappings of social status and face management that inhibit much f2f communication. People often feel a sense of immediacy and relative anonymity with e-mail that leads to greater self-disclosure. People have time to think and compose, and may therefore communicate more articulately than in other circumstances. The lack of formality of applications like e-mail mean people are more likely to respond to e-mail than to other media such as letters of faxes. Paradoxically, these same factors may contribute to some people behaving in obnoxious or antisocial ways.


In electronically mediated communication the absence of visual cues can have therapeutic advantages for some people. For example the Internet may provide opportunities for people who are too depressed to conduct social life in the real world (Yamuchi & Coget, 2002). The Internet may be a source of interaction for people who may be isolated for reasons of geography or disability. The bodiless nature of on-line communication has been suggested as an asset, which enhances communication and a sense of safety in online support groups for women with eating disorders (Walstrom, 2000). For people with rare health problems the Internet may provide the only practical avenue to make and maintain contacts with others with similar problems. A large number of self-help and support groups exist on the Internet for virtually any problem imaginable and on-line self-help groups hosted by mental health professionals are being promoted. A therapeutic synergy may be created by sharing the administrative and therapeutic functions between professionals / hosts and members of on-line support groups (Hsiung, 2000).


The Internet may be a means for many people to develop confiding relationships and a sense of social connectedness. Lower levels of social connectedness are associated with a higher prevalence of mortality and illness such as depression (Moodie & Verins, 2002). Some research suggests that heavy Internet users have lower levels of social loneliness but higher levels of emotional loneliness compared to others (Moody, 2001). However, it is impossible to obtain a representative sample of the population of Internet users and research on the effect of the Internet on human relationships is contradictory. Large scale surveys of North American users suggest that people do not generally believe that f2f contact with family or friends suffers as a consequence of Internet usage, indeed the main activity that appears to be displaced is watching television (UCLA Center for Communication Policy, 2001). Research examining the use of the Internet by psychiatric nurses relatively experienced with the technology, found that people spent less, but more focused time on-line once the novelty had warn off (Lakeman, 2000).


The Internet has been described as an ‘Identity Technology’. Much of what people do online is self-explanation and presentation and the Internet provides a relatively safe place to try out different roles, voices and identities (Riva & Galimberti, 2001). Some applications require the adoption of aliases. The identities and relationships developed using the Internet may be as or more significant than real life identity or relationships. People identify with virtual communities that develop their own norms of behaviour. The international psychiatric nursing list is one such example in which people’s participation and discourse has been described as a process of ‘constructing professional identity’ (Bowers, 1997). Respondents to surveys on the list have described feeling a sense of belonging and enrichment from participation that sometimes buffers against the effects of working in unsupported or impoverished work places (Lakeman, 1996). Such communities have the capacity to transcend and sometimes transform culture.


Implications of the Internet for the future of Psychiatric Nursing

The pace of technological change is so rapid that even the pundits cannot accurately predict the future impact of the Internet. Impediments such as low bandwidth, the socio-demographic characteristics of Internet users, security and privacy issues, funding and the capacity to adapt traditional practices to Internet environments will all impact on the uptake and usefulness of the Internet psychiatric nurses. However, whatever the field of work psychiatric nurses are involved in the Internet provides a means to participate and develop partnerships.



Probably the most rapid growth in the use of the Internet has occurred around nursing education. At the University of Queensland enrollment, payment of fees, submission and return of assignments, library access and much courses content is undertaken using the Internet. Many students will never physically visit the main campus. Over the last few years most peer reviewed journals have been made available on-line. Journals that are not on-line will not get the circulation of on-line sources. With an unprecedented amount of information at students’ fingertips it has become increasingly important to foster skills in critical appraisal and information consumership. Whilst in the future teaching people the technical aspects of using the Internet will be as redundant as teaching most people how to use an electric jug, there is a growing need to develop and share knowledge of interpersonal processes and the Internet. On-line therapeutic interaction and counseling will evolve into a discipline and be integrated into curricula for the helping professions.


In Queensland it has become routine for lectures and in-service education to be delivered by video conferencing. As bandwidth constraints are resolved the teaching of at least some aspects of nursing will be undertaken in virtual environments. Most post-graduate study will be undertaken via distance and the expertise of the available academics will become the major draw card for students. Educational institutions will play a greater role in facilitation, rather than being the direct providers and employers of teachers. The institutions that are able to draw the greatest pool of international expertise and have the most flexible delivery and assessment systems will have competitive advantage in a global environment.



As increasing numbers of psychiatric nurses become networked to professional communities, local tradition and authority will loose dominance in influencing local practice. Nurses can share their ideas, and intuitions with colleagues far removed from their situation. The dissemination of ideas and practices can be rapid and far-reaching using the Internet. For example Phil Barkers, ‘Tidal Model’ has had considerable influence in Australasia and Asia, in a large part because of his accessibility and the fostering of personal relationships via e-mail.


The advantages in being able to communicate and collaborate with colleagues from other services are particularly apparent for people living in rural and remote areas. Already, telemedicine is a working reality in countries such as Australia and Canada (see: Hailey, 2001; Hailey, Roine, & Ohinmaa, 2002; Watson, Gasser, Blignault, & Collins, 2001) and is well received by most patients (Simpson, Doze, Urness, Hailey, & Jacobs, 2001). Telemedicine still requires relatively expensive technology and the inconvenience of patients traveling to a clinic with video conferencing facilities. The Internet will enable consumers to access professional consultation from their own homes.


On-line psychotherapy and clinical-supervision services are rapidly being developed. Indeed, psychiatric nurses such as Ben Davidson are at the forefront of promoting and researching on-line clinical supervision and therapy (see: demand and need for on-line therapeutic intervention is already present. In 2001 the U.K. Samaritans made over 64,000 e-mail contacts (The Samaritans, 2002). On-line therapy, crisis intervention and supervision are not just limited to e-mail exchanges but can take advantage of almost any Internet communications application (Fenichel et al., 2002). Concern remains for researchers, patients and clinicians alike as to how therapy might best be facilitated in cyberspace. The prospect of cyber-therapy also renews interest in what the ingredients of successful therapy actually are. Clearly, certain environmental, therapist and client factors need to be present and technology needs to facilitate a sense of presence and connection.


Clinicians need to be alert to the reality and significance of Internet relationships for harm and for good. All psychiatric nurses need to develop an awareness of on-line resources and communities that they might recommend to people. Psychiatric nurses also need to be alert to cues of Internet addictions and compulsions and the possibilities of noxious on-line experiences contributing to people’s distress. Ethical and practical problems abound. For example, how to respond to people who seek help on-line, whose identities and whereabouts remain uncertain and when the nurse is not in a professional role. Opportunities exist for collaboration and partnerships with consumers, and other interested groups to develop and maintain on-line resources to facilitate mental health. Consumers are likely to become increasingly sophisticated in their use of the Internet and in their understanding of treatment options.



Apart from the obvious and already established practices of using e-mail to collaborate and communicate with other researchers, the Internet provides a wealth of research opportunities. Very little is known about how to facilitate the optimum therapeutic or educational experience from the evolving technologies. At present, there is almost no research-based evidence on the effect of Internet use on consumer outcomes (Bessell et al., 2002).


The Internet is the most comprehensive archive of written material representing our world, people’s opinions, concerns and desires (Eysenbach & Till, 2001). As such, it represents a wealth of research opportunities. Internet communities such as e-mail lists, chat rooms, bulletin boards and newsgroups are rich sources of research participants and data for qualitative analysis. The WWW readily lends itself to the deployment of questionnaires, and the researcher has a range of inexpensive synchronous (real-time) and asynchronous methods of communicating with participants and collaborators at their disposal.


Any researcher needs to proceed cautiously with undertaking research using the Internet. Despite, the seemingly public accessibility of textual data, members of communities do not always appreciate being solicited for research. They may consider communication to be taking place in a private, rather than public space. It is relatively easy to breach confidentiality by quoting exact words of message posts to newsgroups, as the original message may easily be found using a search engine (Eysenbach & Till, 2001). The following factors ought to be considered by researchers and institutional review boards considering studying Internet communities (Eysenbach & Till, 2001, p.1105):


The Internet provides opportunities to involve people who may be geographically isolated, or unlikely to be involved using other methods of recruitment. For example, Barry (2001) described using the Internet to recruit participants into a study examining the acculturation experiences of Arabic immigrants to North America. The sense of anonymity and the use of e-mail to rapidly respond to questions and concerns, were assets in recruiting people who were often suspicious of other media and the motivations of researchers. The Internet allows on-going dialogue between researchers and participants and potentially enables meaningful partnerships to occur at every stage of the research process. Dissemination of findings can be immediate and not limited to peer reviewed journals with their limited circulations.



Whilst not presently impinging dramatically on the face to face work of the psychiatric nurse working in a typical acute in-patient mental health unit, the Internet has already imposed itself as an influence on the systems and communities in which the nurse works. People were initially sceptical of the use of the telephone:-

The ‘telephone’ has too many shortcomings to be seriously considered as a means of communication. The device is inherently of no value to us

            Western Union internal memo, 1876

Today it is difficult to conceive of the work of the community psychiatric nurse (CPN) without a telephone. Just as the telephone has become an integral (but sometimes loathed) part of our everyday lives and transformed the way we relate to people, so will the Internet. Yet, nurses are challenged by lack of research, policy and preparedness to even respond to the issue of Internet communication between nurses and consumers.


The demographic composition of the Internet has become more diverse but relatively affluent people still largely populate the Internet. This will limit opportunity to engage and share the benefits of the Internet with a substantial number of people who often most need our service (Lakeman, 1997). The Internet may seem largely irrelevant in the face of the problems with which some people live. However, nurses have a duty to use what avenues they can to advocate and collaborate to improve the conditions for people whom they care for. The Internet will increasingly become a tool for political lobbying and participation.


The Internet has become a tool for information foraging, dissemination and communication. In the process it is transforming research, education and practice. New opportunities arise to collaborate and communicate with other professionals and consumers. The Internet plays a role in shaping the identities of people and communities. Being different from other media it poses a challenge to clinicians, teachers and researchers to adapt practices previously thought to be only possible to conduct using other means of communication. The Internet promises huge benefits for clients, clinicians and communities. However, we must adapt to, improve and use the technology to improve health and the quality of our lives. As Yellowlees (2001, p.166) reminds us, “... there are those who make things happen, those who watch what happens and those who wonder what happened”. Nurses need to capitalise on the Internet to make positive things happen for them, their communities and consumers.




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