Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Psychiatric–Mental Health Nurses’ Exposure to Clients With Problematic Internet Experiences: A Mixed-Methods Pilot Study



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The current study explored the type and number of problematic Internet experiences (PIE) encountered by psychiatric–mental health nurses (PMHN) in clinical practice and analyzed PMHNs’ clinical cases of clients with PIE. A mixed-methods quantitative survey with a qualitative component measured the types and number of PIE cases via a descriptive survey and derived themes using narrative inquiry methodology from written case descriptions. A sample of 16 PMHNs provided quantitative data and nine participants summarized clinical cases. PMHNs reported 92 adult and 33 child cases of PIE. Six themes were derived from the narrative data: (a) searching for pornography; (b) developing online romantic relationships; (c) online gaming is ruining my life; (d) spending excessive time on the Internet; (e) coming to terms with online sexual behaviors and addiction; and (f) cyberbullying. Implications for PMHN practice include the need for further assessment and intervention as PIE increase in the future. [Journal of Psychosocial Nursing and Mental Health Services, 53(10), 31–40.]

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Click here to read a Letter to the Editor about this article.

The current study explored the type and number of problematic Internet experiences (PIE) encountered by psychiatric–mental health nurses (PMHN) in clinical practice and analyzed PMHNs’ clinical cases of clients with PIE. A mixed-methods quantitative survey with a qualitative component measured the types and number of PIE cases via a descriptive survey and derived themes using narrative inquiry methodology from written case descriptions. A sample of 16 PMHNs provided quantitative data and nine participants summarized clinical cases. PMHNs reported 92 adult and 33 child cases of PIE. Six themes were derived from the narrative data: (a) searching for pornography; (b) developing online romantic relationships; (c) online gaming is ruining my life; (d) spending excessive time on the Internet; (e) coming to terms with online sexual behaviors and addiction; and (f) cyberbullying. Implications for PMHN practice include the need for further assessment and intervention as PIE increase in the future. [Journal of Psychosocial Nursing and Mental Health Services, 53(10), 31–40.]

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Computers, tablets, and smartphones, all Internet-based, are part of individuals’ daily lives. A propensity for overuse and misuse exists. Computer addiction, Internet addiction disorder (Young & Rogers, 1998), excessive Internet use (Weinstein & Lejoyeux, 2010), and problematic Internet use (Aboujaoude, 2010) have been discussed in the literature as early as the 1990s as behavioral addictions. Mitchell, Becker-Blease, and Finkelhor (2005) describe this phenomenon as problematic Internet experiences (PIE). Behavioral addictions result from actions that are compulsive and impulsive in nature and produce neurologic dopamine flooding causing pleasure. Dopamine release is associated with the brain’s reward center and drug, alcohol, gambling, sex, eating, exercise, and shopping addictions (Ascher & Levounis, 2015; Carnes, 2001; Rosenberg & Feder, 2014); tanning overuse (Levounis, Mohamid, & Heckman, 2015); work addiction (Ascher, Avery, & Holoshitz, 2015); problem texting and e-mail use (Zaman & Lache, 2015); love addiction (Briggie & Briggie, 2015; Mellody, 2003); social media overuse (Griffiths, Kuss, & Demetrovics, 2014); problematic mobile phone use (Chóliz, 2010); Internet gaming (Taneli, Guo, & Mushtaq, 2015); and kleptomania (Zerbo & Deringer, 2015).

Internet gaming disorder was recently entered into the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) appendix as an emerging disorder that is not in official nomenclature. Internet addiction, PIE, or sex addiction (related to cybersex and online pornography) have not yet been included in the DSM-5 (APA, 2013). These addictions, however, are well described in the literature, observed, and treated by mental health professionals. Clinical manuals have been developed to treat behavioral addictions (Young & Nabuco de Abreu, 2011). PIE include compulsive sexual behaviors via use of chat rooms, online adult and child pornography, and Internet infidelity through e-mail and Facebook® (Carnes, 2001; Weiss & Schneider, 2015). Inpatient and outpatient facilities across the United States treat sex addiction, which is different from sexual offending. Sex addiction can escalate with the use of Internet pornography. In some cases, child pornography appears. If detected by authorities, individuals are prosecuted as sex offenders. Psychiatric–mental health nurses (PMHNs) are seeing patients and families distressed from computer/Internet addiction and want to know more. The incidence of PIE cases will likely grow, and with sex addiction, perhaps to epidemic levels (Lofgreen, 2012). News events have publicized Internet sexting by a United States Congressman (“Milestones,” 2011) and state government officials who were prosecuted or resigned their posts for using government computers to access and view pornography (“Pennsylvania porn,” 2014).

Background and Significance

In 2011, 75.6% of U.S. households reported having a computer, compared to 8.4% in 1984. More than 70% of households reported accessing the Internet in 2011—an 18% increase since 1997 (U.S. Department of Commerce, Economics and Statistical Administration, & U.S. Census Bureau, 2013). The most frequently searched topic on the Internet is sex (Freeman-Longo & Blanchard, 1998). Aspects of the online environment make it particularly luring to troubled users and promote addictive behaviors.

Wallace (1999) first noted that the Internet changes the way individuals think, feel, and behave in the online world versus reality. Suler (2004) coined the term “online disinhibition effect” (p. 321) to describe how individuals act differently online. The Internet accelerates sexual compulsions, such as online pornography and masturbation (Cooper, Putnam, Planchon, & Boies, 1999). Cooper (1999) described the Triple-A-Engine: accessibility, anonymity, and affordability. Young, Cooper, Griffiths-Shelley, O’Mara, and Buchanan (2000) used the term ACE for accessibility, convenience, and escape to describe Internet compulsive behaviors. These authors emphasized that users do and say things online that they would not normally do or say (Cooper, 1999; Young et al., 2000). Anonymity allows individuals to engage in fantasy, escape consequences, and access sexual content (Delmonico & Griffin, 2011).

Types of Internet Addictions

Internet addiction is a term that was first used by Young (1998) to characterize five problematic Internet-related issues: (a) cybersexual addiction, (b) cyber relationship addiction, (c) net compulsions, (d) information overload, and (e) addiction to interactive computer games. Internet addiction today also includes excessive e-mail/text messaging (Weinstein & Lejoyeux, 2010). Cybersexual addiction is use of adult websites for cybersex and cyberporn. Cyber relationship addiction is over-involvement with online relationships. Net compulsions include online gambling, shopping, and stock trading. Information overload is excessive web surfing and database searching. Addiction to interactive computer games (i.e., Internet gaming disorder) is the compulsive playing of games, either individually or peer-to-peer (Beard & Wolf, 2001; Block, 2008).

Internet addiction involves the need to escape from oneself and may explain excessive use (Weinstein & Lejoyeux, 2010). Individuals who experience Internet addiction use it for extended periods of time, isolate themselves, and hyper-focus on the activity. Individuals with PIE neglect personal health, nourishment, and hygiene. Sleep deprivation for hours or days results in sleep-deprived psychosis. A decrease in activity and socialization occurs. Computer obsession can result in neglect of real-life personal relationships up to divorce. Withdrawal, known as cyber-shakes (i.e., psychomotor agitation and typing motions of the fingers), can also include dry eyes; carpal tunnel syndrome; repetitive motion injuries of the hands, wrists, neck, back, and shoulders; migraine headaches; and numbness and pain in the thumb, index, and middle fingers (Young, 1998).

Computer addiction shows poor judgment and results in low grades, job loss, and indebtedness (Christensen, Orzack, Bagington, & Patsdaughter, 2001; Wieland, 2005). Tolerance and withdrawal can occur (Greenfield, 2011). Tolerance develops when an individual needs to spend more time online for stimulation to uplift the mood and feel better. Notably, if the Internet does not interfere with the individual’s life, Internet addiction is not occurring.

Lack of Psychiatric Nurses as Mental Health Care Providers in Previous Surveys of Problem Internet Experiences

Mitchell et al. (2005) conducted a study to develop the Survey of Internet Mental Health Issues (SIMHI), an inventory of 11 categories. Categories include: overuse, pornography, infidelity, sexual exploitation and abuse, gaming/gambling/role-playing, harassment, isolative-avoidant use, fraud/stealing/deception, failed online relationships, harmful influence websites, and risky or inappropriate use. In Phase 1, a postcard survey was sent to 31,271 mental health professionals; 7,841 valid returns were received (25% response rate). A detailed survey (Phase 2) was designed and pretested through semi-structured interviews with a variety of mental health professionals. Of the 3,398 consented respondents, 2,170 returned a completed follow-up survey (64% response rate). The purpose of the exploratory study was to capture the range of Internet experiences. No PMHNs were represented.

Wells, Mitchell, Finkelhor, and Becker-Blease (2006) explored exposure to PIE among a national sample of 2,098 social workers, psychologists, marriage and family therapists, and other credentialed mental health professionals; an exception was PMHNs. Most participants (75%) had worked with clients with some PIE. Study participants (N = 1,516) were asked if they had considered assessment for PIE as a usual intake process. Forty-three percent reported that PIE was part of an initial assessment. Only one fifth of mental health professionals had received some PIE education. Most had attended continuing education offerings on the topic. Fifty percent of participants stated sex addiction or addiction to cybersex was the focus of education. More than 75% desired additional information.

Mitchell and Wells (2007) conducted a study to determine whether PIE was considered a primary or secondary presenting problem for mental health professionals. Data were derived from clinical reports of 1,441 client cases of youth and adults in the United States. (Nurses again were not represented in the sample.) Findings indicated PIE as a primary concern was related to overuse of the Internet; use of adult pornography and child pornography; sexual exploitation perpetration; and gaming, gambling, or role-playing. The following issues were identified to be either primary or secondary: isolative-avoidant use, sexual exploitation victimization, harassment, perpetration, and online infidelity.

No nursing research studies related to PIE were identified. Nursing research is needed to determine to what extent clients with PIE present to PMHNs and, secondarily, what types of behaviors are occurring. As PMHNs comprise the largest group of U.S. mental health workers, it is imperative to gain insights.

Theoretical Framework

Optimal experience based on the concept of flow (Csikszentmihalyi, 1990) is the theoretical framework of the current study. Flow is described as “a state in which people are so involved in an activity that nothing else seems to matter. The experience itself is so enjoyable that people will do it even at great cost, for the sheer sake of doing it” (Csikszentmihalyi, 1990, p. 4). Flow is a component of the neurobiology of addiction to pleasurable behaviors, including sex and other compulsive activities mentioned previously (Csikszentmihalyi, 1990).


The purpose of the current pilot study was to: (a) explore the extent of PIE encountered by PMHNs in clinical practice and (b) describe PMHNs’ clinical cases (client narratives) of PIE. Research questions were:

  • To what extent are PIE occurring in clients who are seen in PMHN practice?
  • What are the narratives of clinical cases of clients who divulge their PIE behaviors to PMHNs?



A mixed-methods design was used. Quantitative descriptive survey design (Grove, Burns, & Gray, 2012) was used to gather information on extent and types of PIE. Qualitative narrative inquiry methodology (Clandinin, 2013; Clandinin & Connelly, 2000) was used to analyze written clinical stories.

Sample and Setting

Sixteen participants met the following inclusion criteria: (a) employed as a PMHN and (b) able to communicate in English. This purposive national sample of PMHNs represented those who worked in inpatient and outpatient areas, and who were generalist and advanced practice nurses (APNs). Participants were contacted via postings in a professional psychiatric nursing association discussion board and through snowball sampling. Snowball sampling entails participants suggesting other potential participants (Grove et al., 2012). Verbal and/or written explanations regarding consent were provided via e-mail or telephone. Sixteen participants completed the SIMHI; nine (56%) completed the request to describe clinical cases. Data collection continued until no new cases became available to the researcher (D.M.W.) and theoretical saturation occurred (Bowen, 2008; Streubert Speziale & Carpenter, 2010). The university Institutional Review Board approved the study. Confidentiality was ensured by de-identification of data. Data were saved during data collection and analysis and manuscript preparation and then destroyed.

The sample who completed the SIMHI were predominantly women (n = 14, 87.5%), White (N = 16, 100%), had a mean age of 54 years, and were married (56%), with a master’s degree in nursing (n = 10, 62.5%), a doctoral degree (n = 1, 6.25%), a master’s degree in counseling (n = 1, 6.25%), or a diploma in nursing (n =1, 6.25%). Three participants did not indicate their educational level (18.75%). Most participants worked in outpatient areas (n = 9, 56.25%), inpatient acute care (n = 3, 18.75%), or private practice (n = 3, 18.25%). Participants identified themselves as clinical nurse specialists (CNS; n = 5, 31.25%), nurse practitioners (NP; n = 3, 18.75%), or a CNS/NP (n = 1, 6.25%). Two (12.5%) nurses identified as staff nurses.

Of the total 16 participants, nine completed qualitative case study reports; seven did not respond. In this sub-group, the majority were women (n = 6, 55.5%), had a mean age of 54 years, were married (n = 5, 50%), and White (100%). The majority were educated at the master’s level in nursing (n = 4, 44%). Thirty-three percent worked in an acute psychiatric unit (n = 3), 55% (n = 5) worked in outpatient settings, and 11% (n = 1) worked in private practice. The majority were NPs (n = 1; 11%), CNSs (n = 2, 22%), CNS/NPs (n = 2, 22%) or considered themselves APRNs with prescriptive authority (n = 2, 22%).


The SIMHI (Mitchell et al., 2005, used with permission) is a record of the number of PIE in a mental health practice. Eleven items in the SIMHI inventory were developed from quantitative and qualitative data in an original two-phase mail survey sent to a random sample of members of the American Psychological Association and National Association of Social Workers. All cases were double coded by project staff to ensure reliability of case types (Mitchell et al., 2005).

The SIMHI is a three-question survey with options to identify both adult and child populations in which PIE have been identified. Table 1 indicates the survey questions and data for the current study.

Findings from Survey of Internet Mental Health Issues (N = 16)

Table 1:

Findings from Survey of Internet Mental Health Issues (N = 16)

Qualitative Design

Narrative Inquiry. Narrative inquiry (Clandinin, 2013; Clandinin & Connelly, 2000) was the qualitative interpretive research methodology used in the current study. Narrative inquiry encompasses “the interdisciplinary study of the activities involved in generating and analyzing stories of life experience (e.g., life histories, narrative interviews, journals, diaries, memoirs, auto-biographies, and biographies) and reporting that kind of research” (Schwandt, 2001, p. 171).

Schwab (1960), Clandinin and Connelly (2000), and Clandinin (2013) describe narrative inquiry based on Dewey’s (1961) view of experience: situation (place), continuity (past, present, and future), and interaction (personal and social).

Narratives have come to be known in the past 10 years in both medicine (Charon, 2006) and the social sciences (Andrews, Squire, & Tamboukou, 2008; Riessman, 2008) in part because of the importance of stories of healing so health professionals can understand illness in the context of patients’ lives (Green & Thorogood, 2011).

Rigor. Rigor is described in terms of trustworthiness (Lincoln & Guba, 1985; Tobin & Begley, 2004). To establish trustworthiness, several aspects were addressed. Credibility was met by completion of the one-page case description form per client, verifying transcripts of participant data typed into documents categorized under each category, member checks by selected participants, and use of a doctorally prepared nurse researcher with experience in qualitative methods who independently read the data and emerging themes in an audit trail to support confirmability and dependability (Lincoln & Guba, 1985). Thick description of data provided for transferability. Triangulation of data entails use of multiple or different sources, methods, investigators, and theories (Denzin, 1978). Triangulation was met with use of two nurse researchers analyzing the data.

Data Collection

The researcher collected brief demographic information (e.g., sex, age, marital status, race, educational level, type of clinical setting where employed, type of role of PMHN). Participants completed the SIMHI and described clinical cases (i.e., narratives) of clients who experienced PIE. Directions on the form included:

Please provide clinical documentation of cases you have experienced with patients who have had problematic Internet use. Keep all information free of identifying information for patient confidentiality and anonymity. Provide, if possible, the type of problematic Internet use, gender, and age of the clinical case.

Participants documented information about clinical cases on a one-page narrative in a handwritten form. Participants were requested to provide as much data as possible but maintain confidentiality.

Data Analysis

Descriptive statistics were used to analyze the quantitative data for adults and children based on the SIMHI questions and demographics of the PMHNs. Narratives were analyzed as to narrative inquiry. Data were deconstructed from a whole to individual parts to form a new whole (Clandinin, 2013; Clandinin & Connelly, 2000). Data analysis (Clandinin & Connelly, 2000) steps included: (a) recruitment and selection of participants; (b) creation of field texts (e.g., interview, text data); (c) verbatim transcription of data; (d) verification of transcription validity through review of transcript text by participants (in the case of interviews); (e) multiple reading of transcripts; (f) thematic analysis; (g) coding of field texts; and (h) creation of interim research texts, then final research texts (i.e., themes).

Coding of field texts requires researchers to analyze the narrative for storylines, events, places where events and actions took place, and interweaving storylines (Clandinin & Connelly, 2000). A new construction of parts makes the content visible and data are presented as a story (Riessman, 2008). Participants’ reflective data of clinical cases were transcribed by the researcher (D.M.W.). The researcher reviewed the transcripts against the original data and corrected them for spelling and accuracy. Saturation of data occurred when no additional themes appeared.


Quantitative Findings

PMHNs (N = 16) reported 92 adult and 33 child cases of PIE. All participants provided direct client services (patients and students) within the past 5 years. More than 87% (n = 14) had clients who had PIE. Participants reported the highest form of PIE in adults was excessive use, followed by romantic or sexual relationships, gaming or role-playing, adult pornography, close-relationship or friendship, sexual approaches/solicitations/behaviors, and other types of PIE. In more than 31% of adults, child pornography was a concern. In children (age 17 and younger), highest ranking PIE were excessive use, with romantic or sexual relationships and gaming or role-playing as the next highest ranking PIE. In the Other PIE category, use of eBay®, chat rooms, Facebook, and searching of surveys and product information were described. Table 1 displays quantitative findings.

Qualitative Findings

Six themes were derived from PMHNs’ clinical narratives of their cases. Themes included: searching for pornography; developing online romantic relationships; gaming online is ruining my life; spending excessive time on the Internet; coming to terms with online sexual behaviors and addiction; and cyberbullying. The majority of cases provided by the nine PMHNs involved searching for pornography; online relationships including online infidelity; face-to-face affairs that resulted from initial online contact; increased levels of online multi-player gaming and use of World of Warcraft®; excessive time online, which stressed family relationships (i.e., using Facebook and Net-Meeting); and sexual behaviors with online use of bondage/discipline/sado-masochistic websites and pornography. Children were targets of cyberbullying as described in a clinical case. Table 2 describes the themes and clinical examples.

Qualitative ThemesQualitative Themes

Table 2:

Qualitative Themes

Discussion and Implications

Study findings confirm that PMHNs are caring for patients with PIE. Nurses were not included in previous research studies of other mental health professionals who were treating clients with PIE (Wells et al., 2006). Study findings noted types of PIE more commonly presented in adults (e.g., overuse of the Internet, adult pornography, child pornography, sexual exploitation, gaming) and they were also seen in the current study’s PMHNs’ clinical cases. These PIE were identified as primary concerns of clients by Mitchell and Wells (2007). Exposure to continuing education on PIEs was not part of the current study; however, given the number of cases and the gravity of these mental health issues as encountered in this pilot study, PMHNs will need additional education on behavioral addiction, assessment, and treatment.

The Searching for Pornography theme is representative of experiences of clients with sex addiction. Sex addiction is described as a compulsive and impulsive condition (Carnes, 2001). Masturbating to online pornography is an acting-out, escalating behavior related to Internet use. Sex addiction can lead to divorce; betrayal felt by partners is devastating. Individual, group psychotherapy, and 12-step programs are available for partners and sex addicts (Carnes, 2001, 2011). Treatment options for sex addiction are geared to interrupting flow (i.e., the compulsive urge to sexually act out due to negative emotions) by making it more difficult to access online pornography and by addressing sobriety measures (Delmonico, 2002). Smartphones will be replaced with flip phones or controls will be placed on computers or smartphones to prevent easy access to the Internet. Clinical cases noted by PMHNs describe the search for online sex and consequential marital distress.

Developing Online Romantic Relationships is a theme confirmed by Griffiths et al. (2014) and Kuss and Griffiths (2011). Romantic relationships are enhanced through social media, such as Facebook (Drouin & Landgraff, 2012; Muise, Christofides, & Desmarais, 2009; Weisskirch & Delevi, 2011). Several studies have described how social media provides a platform for self-disclosure and can lead to jealousy in relationships (Muise et al., 2009). Texting, texting of sexual information, and sexting are related to anxious and avoidant attachment styles. Excessive social media use may increase the incidence of romantic relationships (Griffiths et al., 2014; Kuss & Griffiths, 2011) and development of online infidelity (Young et al., 2000). The current study confirms these findings.

The Online Gaming is Ruining My Life theme is well documented in the psychological literature (Kuss & Griffiths, 2012). Gamers are described as having introversion, neuroticism, and impulsivity. Motivation for Internet gaming addiction is related to play such as coping with negative emotions, stress, fear, escape, dissociation, entertainment, control, recognition, excitement, challenge, and intrinsic need to play the game (Kuss & Griffiths, 2012). Comorbidities of gaming addiction are associated with generalized anxiety disorder, panic disorder, social phobias, depression, and attention deficit/hyperactivity disorder (Allison, von Wahlde, Shockley, & Gabbard, 2006). Massively multiplayer online role-playing games are not the most common online game, but they are highly representative in the literature on online gaming. Examples include World of Warcraft, which was described in four cases by PMHNs in the current study. Depression, anxiety, and social isolation were characteristics of clients treated by PMHNs.

The Spending Excessive Time on the Internet theme is described as a technological addiction (Widyanto & Griffiths, 2006). Young (1998) considers Internet addiction as representing cybersexual addiction, cyber-relational addiction, net compulsions, information overload, and computer addiction to gaming. Griffiths (2000), however, claims that excessive users of the Internet are not “Internet addicts” but use the Internet excessively as a means to fuel other addictions.

Coming to Terms with Online Sexual Behaviors and Addiction emerged as a theme as clients described by PMHNs turned to the Internet to meet their sexual needs. Searching for online sexual relationships and sex addiction (i.e., pornography and masturbation) were described by PMHNs. Sexual addiction and treatment are discussed in the literature (Carnes & Adams, 2010; Young et al., 2000).

Cyberbullying is noted in the reported case of a 10-year-old girl. She was the target of rumors and gossip who developed emotional and behavioral changes and exhibited poor school performance. Cyberbullying is “the use of technologic devices (cell phones and computers) to willfully and repeatedly cause harm to others” (Carpenter & Hubbard, 2014, p. 141). This technology includes e-mail and text messages sent in an effort to threaten, harass, or embarrass someone and to send personal photographs without consent (Moreno & Hornbeck 2011). Bullied victims are at risk for depression; substance abuse; absenteeism and social phobias; weapon carrying; psychosomatic problems; poor relationships with parents; offline victimization and abuse (Gini & Pozzoli, 2013); shame; generalized fear (Powell & Ladd, 2010; Schneider, O’Donnell, Stueve, & Coulter, 2012); and suicidal thoughts, attempts, and completed suicides (Hinduja & Patchin, 2010).

News media has reported on PIE, such as sexual acting out (i.e., viewing online adult and child pornography on government and work computers and inappropriate sexual behaviors perpetrated by adults toward children and youth), by public and government officials, clergy, teachers, coaches, and medical professionals. Nursing research has been relatively nonexistent in exploring these relevant, timely, and distressful issues. As more PMHNs become APNs and see individuals and families in outpatient areas, they will interview more patients with PIE. Nurses in inpatient areas may see PIE as primary or secondary psychiatric problems. PMHNs and APRNs who work in primary care will need assessment guidelines and clinical instruments to identify clients’ specific issues related to their particular type of PIE. Clients across the lifespan first seek care through their primary care provider, making information on PIE important for all age groups. PMHNs need more education on PIE in undergraduate nursing curricula, graduate PMHN practitioner programs, and at national conferences. Treatment with evidence-based models of care will be necessary for PMHNs to do their work (Wieland, 2014).


A limitation of the current study was the small quantitative sample. The sample was predominantly Caucasian women in their mid-50s. Access to PMHNs was made via word of mouth and announcement of the research on a professional nursing discussion board, which may have limited the diversity of the sample. One theme had only one case exemplar (i.e., Cyberbullying). A limitation was the use of narratives in the form of case study written summaries only. More data may have been additionally obtained through interviews of PMHNs.


The Internet is part of modern living. As a behavioral addiction, Internet abuse cannot be totally eliminated, which may make it more difficult than the abstinence model of chemical addiction. Environmental modifications and behavioral approaches may assist patients in managing the compulsive nature of their PIE. In sex addiction, sobriety and other clinical outcomes occur with individual therapy, group psychotherapy, 12-step fellowships, and psycho-education. Some modifications may need to be made in technology, such as use of a flip phone instead of a smartphone, use of filtering software (e.g., Net Nanny® or CovenantEyes® [“Rating Internet filtering…”, n.d.]) and removal of software applications from a smartphone. These are ways to prevent flow. Accountability software, such as Mobicip (access; “The most popular...”, n.d.), is used so therapists can monitor their clients’ illicit Internet website use.

The current pilot study provides new information that PMHNs are in fact treating patients with PIE. This knowledge propels PMHNs to advocate and receive specific education related to PIE. Education and clinical experiences will enable PMHNs to provide expert evidence-based treatments for disorders that are a direct result of living in a technologically high-speed and complex 21st century.


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Findings from Survey of Internet Mental Health Issues (N = 16)

Question Response, n (%)
1. In a professional capacity, have you provided direct services to clients (including patients and students) within the past 5 years? Yes, 16 (100) No, 0
2. Have you ever had a client who had any type of problematic Internet experience? This does not have to be the presenting problem or complaint. (Internet meaning connecting a computer or television to a telephone or cable line to use things such as the World Wide Web, e-mail, instant messaging, and chatrooms). Yes, 14 (87.5) No, 1 (6.25) No response, 1 (6.25)
3. Did the problematic experience(s) involve any of the following? Adults (18 and older), n (%) Children (age 0 to 17), n (%)
Yes No No Response Yes No No Response
Adult pornography 10 (62.5) 4 (25) 2 (12.5) 2 (12.5) 2 (12.5) 12 (75)
Child pornography 5 (31.25) 7 (43.75) 4 (25) 0 4 (25) 12 (75)
Sexual approaches, solicitations, or behavior 7 (43.75) 6 (37.5) 3 (18.75) 7 (43.75) 6 (37.5) 3 (18.75)
A romantic or sexual relationship 11 (68.75) 3 (18.75) 2 (12.5) 11 (68.75) 3 (18.75) 2 (12.5)
A close relationship or friendship 9 (56.25) 4 (25) 3 (18.75) 9 (56.35) 4 (25) 3 (18.75)
Fraud or other scams 1 (6.25) 10 (62.5) 5 (31.25) 1 (6.25) 10 (62.5) 5 (31.25)
Excessive use 14 (87.5) 0 2 (12.5) 14 (87.5) 0 2 (12.5)
Gaming or role-playing 11 (68.75) 2 (12.5) 3 (18.75) 11 (68.75) 2 (12.5) 3 (18.75)
Racist or hate material 0 11 (68.75) 5 (31.25) 0 11 (68.75) 5 (31.25)
Violent material 1 (6.25) 10 (62.5) 5 (31.25) 1 (6.25) 10 (62.5) 5 (31.25)
Aggressive behavior (e.g., harassment, stalking) 2 (12.5) 9 (56.25) 5 (31.25) 2 (12.5) 9 (56.25) 5 (31.25)
Other problematic Internet experience?a 7 (43.75) 5 (31.25) 4 (25) 7 (43.75) 5 (31.25) 4 (25)
4. What is the total number of adult and child clients with problematic Internet experiences you have seen or treated? (Please use the age at the time treatment began). Cases: 92 No responses to age at which problem began Cases: 33 No responses to age at which problem began

Qualitative Themes

Theme Clinical Examples of Problematic Internet Experiences
Searching for Pornography

A 32-year-old man was treated with comorbid dysthymia and sex addiction/use of Internet pornography.

10- and 12-year-old boys were using a popular Internet game and, via a web link, became involved with a discussion group involving adult bondage and pornographic activity.

A 62-year-old man with degenerative joint disease of the spine and major depressive disorder was looking at pornography all day and chronically masturbating.

Developing Online Romantic Relationships

A woman developed a relationship online. A man she met presented himself to her home, uninvited, requesting sex. He was not allowed in the house, and he left. Despite knowledge of danger, the patient refused to stop Internet use in chat rooms. The patient interacted with predators who attempted to gain sex, money, and pain medications from her on several occasions.

A 32-year-old woman began an Internet relationship that progressed to a physical affair.

A 41-year-old married man, father of three children, whose wife was employed in an administrative position and was having an affair. She was “up all night using Facebook®.” Communication between husband and wife soured as the wife spent all of her time on the computer. Wife did not clear Facebook messages from the family computer, which showed evidence of her affair.

Online Gaming is Ruining My Life

College-age man with Asperger’s disorder was using online gaming 20 hours per day, which interfered with work, chores, and family interactions.

Four participants were described in separate cases as playing World of Warcraft®, typically at night, making them late for work, having problems on the job, and having little else to occupy their free time.

A single mother of two boys, ages 13 and 15, was referred due to a family crisis. The 15-year-old boy was doing extremely poorly in school due to spending excessive time on the Internet, playing games, and using marijuana. School officials stated they have made several attempts to engage the boy, but “can’t compete with his Internet activities.”

Spending Excessive Time on the Internet

A 55-year-old woman regularly uses Facebook to argue and be “at odds” with others.

A 33-year-old married man, father of three children, was referred due to stress at work and in his personal life. Patient reported low self-esteem after contacting old friends on Facebook. Individuals on Facebook were making comments about their various achievements after leaving high school. The man considered himself less successful than the others and began to dwell on this.

Multiple cases of patients who spend a lot of time online shopping, gaming, and not working because of excessive Internet use at home.

Coming to Terms with Online Sexual Behaviors and Addiction

A 51-year-old married woman who presented with “I need therapy or my marriage is over” described that her husband reported that he “has been a lesbian in man’s clothes.” He enjoys sadomasochism clubs and “likes to be submissive.” He turned to the Internet to meet his sexual needs. He would hook up on bondage/discipline/sadomasochistic chat rooms. He was often online while at work, most evenings, and weekends.

A 51-year-old married man was using adult pornography and searching for same-sex partners on the Internet. The patient spent considerable time checking requests and searching sites for possible sexual relationships.

A 32-year-old man living in a residential treatment center for sex addiction for use of Internet pornography. The patient is being treated for depression, and is currently in remission.


A 10-year-old girl presented with her adoptive mother for an evaluation of long- standing fears of being alone. The patient was adopted from a Russian orphanage at age 9 months. No history of her family is known. She began to develop fears at age 5. Behavioral interventions, such as cognitive-behavioral therapy, helped extinguish fears. She began to have difficulties with a female peer “who was nice 1 minute and mean the next.” This girl is now targeting the patient. The patient started to have increased difficulties when the mean girl and her peers began to harass and bully her on the Internet by posting rumors and gossip. This situation resulted in the patient expressing irritability, argumentativeness, oppositional behavior, withdrawn behaviors, and poor grades in school.


Wieland, D.M. (2015). Psychiatric–Mental Health Nurses’ Exposure to Clients With Problematic Internet Experiences: A Mixed-Methods Pilot Study. Journal of Psychosocial Nursing and Mental Health Services, 53(10), 31–40.

  1. Internet-based devices, such as computers, smartphones, and tablets, are part of daily life, but have the potential to be misused or overused, resulting in a behavioral addiction.

  2. Behavioral addictions (e.g., gambling, sex, gaming, work, and excessive use of social media, e-mail, and the Internet) have the same neurobiology as substance use disorders.

  3. All mental health professionals, including psychiatric–mental health nurses, are seeing clients who have experienced problematic Internet use, but more education, assessment measures, and evidence-based treatment options are needed.

  4. Problematic Internet use affects everyone across the lifespan, with youth particularly affected by online relationships, excessive Internet use, and cyberbullying.

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Dr. Wieland is Associate Professor, School of Nursing and Health Sciences, La Salle University, Philadelphia, Pennsylvania.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Diane M. Wieland, PhD, MSN, RN, CRNP, PMHCNS-BC, PMHNP-BC, CNE, Associate Professor, School of Nursing and Health Sciences, La Salle University, 1900 West Olney Avenue, Philadelphia, PA 19141; e-mail:

Received: April 12, 2015
Accepted: August 03, 2015


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