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Online mental health resources have been proposed as an innovative means of overcoming barriers to accessing rural mental health services. However, clinicians tend to express lower satisfaction with online mental health resources than do clients.
To understand rural clinicians’ attitudes towards the acceptability of online mental health resources as a treatment option in the rural context.
In-depth interviews were conducted with 21 rural clinicians (general practitioners, psychologists, psychiatrists, and clinical social workers). Interviews were supplemented with rural-specific vignettes, which described clinical scenarios in which referral to online mental health resources might be considered. Symbolic interactionism was used as the theoretical framework for the study, and interview transcripts were thematically analyzed using a constant comparative method.
Clinicians were optimistic about the use of online mental health resources into the future, showing a preference for integration alongside existing services, and use as an adjunct rather than an alternative to traditional approaches. Key themes identified included perceptions of resources, clinician factors, client factors, and the rural and remote context. Clinicians favored resources that were user-friendly and could be integrated into their clinical practice. Barriers to use included a lack of time to explore resources, difficulty accessing training in the rural environment, and concerns about the lack of feedback from clients. Social pressure exerted within professional clinical networks contributed to a cautious approach to referring clients to online resources.
Successful implementation of online mental health resources in the rural context requires attention to clinician perceptions of acceptability. Promotion of online mental health resources to rural clinicians should include information about resource effectiveness, enable integration with existing services, and provide opportunities for renegotiating the socially defined role of the clinician in the eHealth era.
Rural mental health presents a unique set of challenges in which limited resources are available to service communities already burdened by significant risk factors for mental health problems, including social isolation [
In Australia, recent developments in online technology and expanded infrastructure supporting Internet access [
Recent studies have assessed different approaches to the delivery of online mental health resources, including community-based models [
While some have suggested that online mental health resources may make a significant contribution to rural mental health service delivery [
Symbolic interactionism was employed as a theoretical framework for the study. Symbolic interactionism asserts that humans make decisions about action based on the symbolic meanings ascribed to these actions, which are learned through social interactions and reflection on the self from the imagined perspective of others [
This study adopted a qualitative descriptive approach [
Summary of participant characteristics.
Characteristic | Phase 1 | Phase 2 |
Age, mean (SD), years | 47 (10.6) | 52 (7.9) |
Gender (female, male) | 10 female, 3 male | 3 female, 5 male |
Experience providing mental health services, mean (SD), years | 18.2 (9.6) | 16.9 (8.1) |
Remote/very remote mental health service experience, n (%) | 4 (31) | 7 (87.5) |
General practice (n) | 4 | 4 |
Mental health specialists (n) | 9 | 4 |
In Phase 1, sampling was through formal invitations sent to community-based rural mental health organizations and convenience sampling of rural mental health specialists (psychologists, psychiatrists, and clinical social workers) and general practitioners. Two of the authors, a rural health researcher (CS) and an experienced rural psychiatrist (GR), developed an initial discussion guide in consultation with existing literature (see
Anecdotal reports from clinicians during study development and previous research [
In Phase 2, purposeful sampling recruited clinicians with experience delivering mental health services in remote or very remote settings (Accessibility Remoteness Index of Australia >5.92) [
Based on data collection and analysis in Phase 1, the researchers developed a set of vignettes describing three hypothetical, rurally based clinical scenarios in which referral of a client to online mental health resources might be considered (see
Interview transcripts were analyzed using NVivo Version 10, following an iterative process of open, focused, and theoretical coding to extract codes, categories, and themes from the interview transcripts. Relational coding was used to articulate relationships between open codes and to identify categories [
Rigor of the research process is demonstrated by its credibility, dependability, confirmability, and transferability [
The Human Research Ethics Committees of the University of Western Australia (RA/4/1/4660) and the Western Australian Country Health Service (2012:01) approved the study protocols.
Clinicians framed their responses using examples drawn from their experiences delivering mental health services in the rural context. The key themes extracted from the transcripts were “perceptions of resources”, “clinician factors”, “client factors”, and “the rural and remote context”. An overarching theme of “integration with existing services” characterized participant responses.
Clinicians typically expressed positive perceptions towards online mental health resources and perceived that client use was on the increase. The perceived effectiveness of online mental health resources was attributed primarily to the provision of clear and easily accessible psychoeducation, which could be used in early intervention, helping clients normalize symptoms and encouraging future help-seeking. Most acknowledged that they received limited feedback from clients who were using the resources, precluding direct comments about clinical efficacy. Some clinicians had identified their own “favorite” resources, which they referred to regularly and integrated into their clinical practice, often by printing handouts for clients. Clinicians emphasized that resources providing clear, quickly accessible information would be most appropriate for clients:
I mean one of the things I noticed is if you get to a home page and there are too many options and go here, go there, and all these things hanging off, it can be quite overwhelming and thinking about some of the minds and emotional states that my clients might be in and how this is going to feel for them.
An emphasis on “usability” had the added benefit of enabling clinicians to integrate the resources within the time demands of their clinical practice, allowing them to guide clients through an online resource or quickly access printable information. Others suggested that user-friendly online resources could be made available on public computers in clinic waiting rooms, assisting in psychoeducation, or providing material for further discussion with the clinician.
Clinicians preferred to be familiar with online mental health resources prior to recommending them to clients. However, they experienced difficulties finding time to explore the range of available resources:
The brief look I have had has been done on the run…with a specific client in mind just to see what was there…it hasn’t been done with sufficient time and focus to really seriously engage and immerse myself with what is there…
Clinicians who were younger and trained more recently tended to show acceptance for the integration of online approaches within their everyday practice:
We’re being trained and informed about these online resources. The older doctors, I don’t imagine, are using them as much.
Older, more experienced clinicians sometimes reported barriers associated with computer literacy, as well as a more general lack of exposure to online mental health resources during their training. For rural clinicians, this was compounded by the difficulties associated with accessing ongoing professional development. Some participants who had received professional development associated with a particular online mental health resource then felt more comfortable integrating it into their routine practice. Clinicians who were unable to access professional development looked to their professional networks for guidance, with mixed results. In one case, a clinician told of receiving criticism from some colleagues for raising a question about online approaches to mental health service delivery:
I recently asked…whether anyone had had any experience [using online mental health resources] among our group and everyone said, “No” and kind of suggested that even to consider that seemed ridiculous.
The benefits and concerns relating to online mental health resources showed some patterns of variation across professional groups. Mental health specialists (psychologists, psychiatrists, clinical social workers) were more likely than general practitioners to identify the provision of psychoeducation and early intervention as benefits. However mental health specialists also emphasized the importance of an ongoing therapeutic relationship as a mechanism for client recovery and were concerned that unsupervised use of online mental health resources might encourage self-diagnosis and “catastrophizing”.
You can get people getting online and then getting into the information online and if you were anxious and a worrier before you started wait ‘til you have spent a couple of hours online looking at how anxious and worried you really could be, so I think there can be a bit of a snowball, some catastrophizing can occur.
General practitioners, on the other hand, tended to identify the capacity for clients to access psychoeducation in their own time as a benefit. Both groups endorsed the ability of online mental health resources to enable greater access to mental health services, but were concerned about the lack of ability to follow up with clients about their progress.
Participants identified a range of client factors thought to influence suitability for referral to online mental health resources. Younger people (particularly adolescents) were perceived as having greater computer literacy and being more willing to seek information online. Those with common mental disorders such as anxiety or depression, and symptoms in the mild to moderate range, were also considered to be more suitable than clients with complex diagnoses or severe and persistent symptoms:
Any [condition] that sort of begs the question about psychoeducation, you know what can people find out themselves, how can they gather knowledge quickly and effectively themselves.
Clients who were prone to excessive rumination or who lacked the motivation or attention to read information online were considered less suitable. Participants also expressed concern that some clients in rural areas lacked private Internet access, had reading difficulties, or lower levels of computer literacy.
Clinicians consistently identified the rural and remote context as one in which people had less access to mental health services, and less choice among service providers. They reported that concerns about anonymity in small communities left many rural clients unwilling to access specialist mental health services. Online mental health resources provided an opportunity for rural clients to access information confidentially, and clinicians endorsed use of the resources where they might assist in normalizing symptoms and encouraging future help seeking. On the other hand, some clinicians identified the potential for certain rural environments to be a recipe for social isolation and rumination and saw the potential for online mental health resources to have a negative impact, particularly if used as a sole source of information:
In certain particularly remote environments that might then intensify the focus on you know what comes through this [online] medium.
Clinicians reported that many rural clients lacked reliable Internet access or sufficient privacy to access online mental health resources confidentially. While regional centers were relatively well serviced, access was less consistent in more remote areas, and the lack of community resources marginalized poorer people. One clinician felt that this constituted an area of rural disadvantage:
Often online services have been looked at as, you know, the great hope for areas where there aren’t real services for people, but where there isn’t adequate Internet access, you are further marginalizing people who live in remote areas who now don’t have access to two different services…
Some clinicians who expressed concerns about rural disadvantage feared that a reallocation of investment toward online mental health resources might compromise the provision of adequate community mental health services in rural areas.
In describing their current referral practices or responding to the hypothetical vignette scenarios, clinicians considered the interaction of clinician, client, and resource factors within the rural and remote context. Their responses were characterized by a preference for integration of online mental health resources alongside existing services. Clinicians acknowledged that referral came with the risk of negative outcomes, including the client feeling neglected, experiencing frustration due to poor Internet access or lack of computer literacy, or misinterpreting online information. Some foresaw that this could lead to a loss of trust in the ongoing relationship, perhaps resulting in disengagement, along with an escalation of symptoms, for which they felt personally responsible:
You send someone off to a machine and they kill themselves or their child or something. It would be very hard to live with, wouldn’t it?
Acknowledgment of these risks contributed to a preference for online mental health resources to be used as an adjunct, rather than an alternative, to face-to-face therapy. Clinicians managed the client’s use of online mental health resources, fostering realistic expectations, and using online information as material to further develop their therapeutic relationship with the client:
So what I am trying to do there is…try and manage it so they have a good experience, you know, a positive experience, then they will keep using it, but if they have that sort of frustrating adverse [experience]…then they’ll often overgeneralize and just disengage.
Referral decisions tended to be more polarized when the client experienced unwillingness or severe difficulty in accessing face-to-face services. Some clinicians feared that the use of online mental health resources in this situation might lead clients to disengage entirely from face-to-face services. Others suggested online mental health resources to clients who they felt were likely to disengage, in the hope of establishing a “bridge” for future contact. One clinician felt that the vignette describing “Matthew” (see
If you have the feeling that [client] is not going to come back again, because he can’t be forced, it’s not a decision of mine, it’s a decision of his. Like that [online personality questionnaire] is actually very useful for them to come back…there’s actually material that enables you to provide some more face-to-face work.
In some cases, the potential to refer clients to online mental health resources appeared to have changed the nature of the clinical relationship. Some clinicians referred clients to online mental health resources as a means of strengthening the therapeutic relationship. The “prescription” of homework validated the client’s concern, and access to a second opinion enabled clients to evaluate the clinician’s diagnosis and be more in control of their condition:
People then have permission to become a little bit expert themselves about whatever their condition is.
However, not all clinicians viewed this change in a positive way. One general practitioner referred to clients bringing information from online mental health resources to consultations to support their argument that they did not require medication:
I had a couple of young patients who very clearly were people that you would want to consider medication for, who actually quoted that site as evidence that, yeah, it didn’t have a role.
This paper addresses a gap identified in previous literature [
Rural clinicians showed a preference for integrating online approaches with existing services. For example, the preference that online mental health resources present clear, simple, and quickly accessible information was motivated by concerns for the client but also by a desire to integrate these resources within the time demands of clinical consultations. Others suggested that providing public computers in clinic waiting rooms could be helpful. In both cases, usability was a key factor. The “technology acceptance” model proposes that the perceived usability and perceived usefulness of a technological aid will determine the extent to which it is accepted and adopted [
Researchers employing symbolic interactionism in the study of online behavior in nonclinical contexts have suggested that while transition to an online medium may “revolutionize” the surface features of social interaction, the underlying attributes of human action and interaction remain stable [
It is important to recognize that the clinician’s decision to refer to online mental health resources occurs from within a pre-existing clinical relationship. Research into the mechanisms of successful psychotherapy has stressed the importance of the clinical relationship or “therapeutic alliance” between the clinician and client [
The convenience sampling method used in the present study is a limitation. It is possible that the sampling method may have led to a self-selecting bias, in which clinicians who were particularly opposed to the use of online mental health resources decided not to participate. The combination of data from a group discussion alongside that collected from individual interviews also adds a further layer of complexity to the analysis. However, we observed similar thematic content in both group and individual interview settings.
Another limitation is associated with the small number of public sector (government-employed) mental health professionals recruited. These professionals typically see a greater proportion of clients with severe and persistent mental illness and may be more sensitive to the risks of adverse consequences. Despite this limitation, those public sector employees who did participate were able to provide insight into the differences experienced in this context and the implications for the use of online mental health resources.
The use of vignette scenarios to frame discussions about referral to online mental health resources is useful for eliciting factors affecting decision making but does not enable reliable inferences to be drawn about future behavioral intentions in similar situations [
The referral of a client by their clinician is just one of a number of ways in which a client may discover and access online mental health resources. Research in Australia has mirrored trends across the developed world, showing that the public are increasingly using the Internet as a source of information about health conditions [
The argument that clinicians negotiate both intrinsic judgments of acceptability and the expectations accompanying their socially defined role, when making decisions about referral to online mental health resources, has a number of clinical and educational implications. First, it suggests that efforts to promote online mental health resources should target professional networks, as well as individual clinicians, using collaborative in-service approaches to address educational requirements and encourage cultural change.
The technology acceptance model suggests that both perceived usefulness and perceived usability will contribute to adoption of the technology [
The impressive results yielded by some trials of online approaches to mental health service delivery have led some commentators to call for “disruptive innovation” to improve outcomes [
Discussion guides used in Phases One and Two.
Vignettes used during Phase Two.
computerized cognitive behavioral therapy
This study was supported by a Rural Clinical School of Western Australia Small Project Research Grant. The authors would like to acknowledge Emma Sodano for assistance with transcription, and the clinicians who participated.
None declared.