Treatment of Internet Addiction
Hilarie Cash, PhD
Co-CEO, along with
Co-Founder Cosette Rae, MSW
reSTART:
Internet Addiction
Recovery Program
Copyright 2011 reSTART Internet Addiction Recovery Program, LLC
Meet Kendle
AGE: 22
GENDER: Male
GAME OF CHOICE: World of Warcraft
(WOW)
STORY: Heart transplant recipient. Started
playing WOW during high school, and
continues to play. Moved up the ranks in
WOW, joined a guild and dropped out of
college. Consumed with playing, he quit
taking his medications. Parents are
concerned that their son may die as a result
of his excessive MMORPG use. He is
unwilling to stop, and denies gaming is a
problem.
(not real name or photo)
Meet Jesse
AGE: 21
GENDER: Male
GAME OF CHOICE: General Surfing and Random
Game Play
STORY: Diagnosed with ADHD in childhood. Gets
online and stays online. Games until 4am most days;
sleep deprived; poor eating habits (gained 100
pounds since high school); conflict avoidant, lies to
family and friends about use. Returned home after
being put on academic probation at college. GPA .5
Doesn’t know how to change his pattern of use;
denies technology use is a problem.
(not real name or photo)
Meet Holly
AGE: 28
GENDER: Female
GAME OF CHOICE: Real Time Strategy (RTS)
Games; Facebook
STORY: Entertains herself watching TV, playing
computer games, surfing the Internet, and
watching movies online. At 21 y/o, she quit
attending college, stopped going to church, and
stole her siblings library cards to use the library
computer after her parents took hers away. Now
28, she lives at home with her family, is
depressed and anxious, and wonders if there is
any help for her problematic use. “I’ve tried
everything and nothing has worked for me. I
still play all the time. I don’t know how to
stop.”
Not real name or photo
A Few Facts
 Internet Use and Gaming Disorder is in the DSM-V,
Section 3, requiring further study
 Internet Addiction has been named the #1 Public Health
Threat in China and S. Korea
 Overall rate of addiction in US is 6-13%
 13-18.5% of College-age American young adults have IAD
 50% of console gaming is done by adults; 25% are 12-17
How Users are Spending
Their Time
RANK Category
Share of Time Share of Time
June 2010
June 2009
1
2
3
4
5
22.7%
10.2
8.3
4.4
4.0
15.8%
9.3
11.5
5.5
4.7
3.9
3.5
12%
3.5
3.3
3.4
3.3
1%
0%
2.8
3.0
-7%
2.7
34.
2.7
37
-2%
-8%
6
7
8
9
10
Social Networks
Online Games
E-mail
Portals
Instant Messaging
Videos and or
Movie Streaming**
Search
Software Manufacturers
Multi-category
Entertainment
Classifieds/Auctions
Other* (e.g. sex)
% Change in
Share of Time
43%
10%
-28%
-19%
-15%
Neurobiology of IAD
“The same neural pathways in the brain that
reinforce dependence on substances can reinforce
compulsive technology behaviors that are just as
addictive and potentially destructive. Almost
anything that we like to do - eat, shop, gamble,
have sex - contains the potential for
psychological and physiological dependence.”
Gary Small, MD
Dopamine: The pleasure chemical
Addiction!
“At its core, addiction isn’t just a social problem or a moral
problem or a criminal problem. It’s a brain problem whose
behaviors manifest in all these other areas,” said Dr.
Michael Miller, past president of ASAM who oversaw the
development of the new definition. “Many behaviors driven
by addiction are real problems and sometimes criminal
acts. But the disease is about brains, not drugs. It’s
about underlying neurology, not outward actions.”
American Society of Addiction Medicine (ASAM) (Aug, 15,
2011) Addiction is a Chronic Brain Disease, not Just Bad
Behaviors or Bad Choices Press Release, PRWEB
The Addictive Applications
Sex/Romance
• Porn
• Online sex/romance chat
• Prostitution
• Live webcam
• Mobile devices (sexting, file-sharing)
Addictive Applications (cont.)
• Gambling/Poker/Trading
• Shopping
• Social Networking
• Surfing/TV/News/Movies/Cartoons/YouTube
• Working (glued to screens)
Addictive Applications (cont.)
Gaming, Casual and Core
(Boundary with sex/romance is
blurred)
• Lapware (games for babies and toddlers)
• Console games
• Computer games
• Mobile games
• Multiplayer
 MMORPG
 MMO
 Strategy
Top Video Games for 2012
•
•
•
•
•
•
•
•
•
•
Call of Duty: Black Ops 11
Madden NFL 13
Halo 4
Assassin’s Creed 111
Just Dance 4
NBA 2K13
Borderlands 2
Call of Duty: Modern Warfare 3
Lego Batman 2
Fifa Soccer 13
Massively Multiplayer
Online Role-Playing Games
(MMOs and MMORPGs)
• Role playing (fantasy)
•
Endless play real time
•
No pause button
•
Peer driven; pressure to play
•
Time Intensive
•
Challenging, stimulating, fun
•
Highly addictive
EXAMPLES
World of Warcraft
Starcraft 2
Farmville (MMO)
Multiple Rewards

Intermittent Reinforcement

Social Reinforcement (competition, cooperation,
social standing, friendships, community)

Sexual/Romantic stimulation

Fantasy Persona (sexy, God-like, etc)

Disinhibition through anonymity

Intellectual stimulation/challenge/
sense of accomplishment
Signs and Symptoms of All Addictions
• Experience of euphoria or a feeling of relief
• Preoccupation
• Loss of control (compulsivity)
• Tolerance (new or more needed to achieve the “high”)
• Withdrawal symptoms
• Use to avoid withdrawal symptoms
• Continued use despite adverse consequences
• Unsuccessful attempts to control or cut down use
• Previously enjoyed activities are abandoned
• Problem avoidance
• Psychosocial impairment
Signs and Symptoms:
Experience of a “high” or a Feeling of Relief
• EXPERIENCE OF EUPHORIA OR A FEELING OF
RELIEF: In the early stages of the addiction, the digital activity
produces a sense of euphoria; in later stages it becomes more and
more difficult to experience the “high”, but the online activity
provides a feeling of relief from tension, anxiety, anger,
depression, or other painful emotions which the individual
experiences when not using the technology.
• Jim loves WOW and all his friends from the game. When he’s not
playing, he feels miserable, but, as soon as he logs on, he feels
comfortable again.
• Consuelo has found Second Life and can’t get enough of it. She
would rather spend her time exploring that universe, finding new
friends and lovers there than doing anything in the real world.
Signs and Symptoms:
Preoccupation or Compulsion
PREOCCUPATION OR COMPULSION: an irresistible
desire or impulse to use the Internet or play video games. A
great deal of time is spent thinking about online activities,
maintaining access to and interacting with the technology.
• Ed finds that he thinks about his Counter Strike game most of
his waking hours, especially during classes. Even when he’s
with his friends he’s thinking of moves that he has played or
wants to try.
• Cassandra listens for the sound of her parent’s footsteps
coming up the stairs so that she can minimize her computer
screen and pretend she is doing her homework.
Signs and Symptoms: Loss of Control
LOSS OF CONTROL: the extent of use is denied or
minimized to self, family, friends or professionals; manipulating,
lying and stealing are used to gain access to the Internet,
desired applications and equipment.
• Jay broke into his parents’ safe to steal money which he then
used to buy a top-notch computer and an i-pad.
• 8 yr.old Kelly hides her smartphone, on which she’s playing
Farmville, pretending to be petting her dog instead, when her
parents come into the room. She’s been given a limit of half an
hour a day to play with it, but she’s discovered that it’s easy to
get around the limit. She’s gotten her Mom’s credit card number
on the phone and buys the stuff she needs to make a great
farm. Mom hasn’t noticed.
Signs and Symptoms: Tolerance
TOLERANCE: Over time, the Internet user or video game
player is unable to achieve the experience of euphoria when
using at a set level. More time or new experiences are required
to achieve the desired effect.
• Nick has been viewing pornography for a few years. He has
grown bored watching adult, heterosexual couples copulating
and has started watching “polyamorous” sex and even
investigating bestiality. He finds the newer porn much more
sexually stimulating.
• Sally loved playing Farmville on her i-phone, alone. Over time,
however, she grew tired of it, although she found she couldn’t
quit. Once she discovered the MMO version of Farmville, she
felt, once again, happy and endlessly intrigued with the game.
Signs and Symptoms: Withdrawal
WITHDRAWL: decreasing or stopping of the Internet
or video game play leads to withdrawal symptoms
(e.g., general malaise, restlessness, irritability, anger,
violence, lack of concentration, dyssomnia, anxiety and
depressive symptoms).
• When Sally stops her online e-bay shopping, she gets
irritable and feels angry with those around her.
• When limits are placed on the amount of time Joe is
allowed online, he sleeps longer than usual and is
resistant to participating in the activities of daily living.
Signs and Symptoms:
Use to Avoid Withdrawal
USE TO AVOID WITHDRAWAL SYMPTOMS:
symptoms of withdrawal may be relieved by engaging
with similar electronic media devices (e.g., TV,
handheld games, gaming devices, cell phone gaming).
• Upon arriving home from work, the first thing Becky
does is get online, or game. If something interferes
with this routine she gets very cranky.
• Devon no longer plays video games since his parents
removed the gaming system. Now he spends the
entire day watching TV, texting and playing with his
cell phone.
Signs and Symptoms: Continued Use
Despite Adverse Consequences
CONTINUED USE DESPITE ADVERSE CONSEQUENCES:
Denial makes it easy to continue in the face of mild-to-severe
harmful effects; awareness makes it more difficult, but the
addict continues anyway.
• Bob’s wife has threatened to leave if he does not spend more
time with her and their children. He does not change his
behavior and continues to play WOW during all his free time.
• Friends, family and peers comment on Sheila’s level of texting
and threaten to take her phone away. She ignores their
comments and continues texting day and night. Her disrupted
sleep is leaving her exhausted and her work is suffering.
Signs and Symptoms: Inability to
Control or Moderate Use
INABILITY TO CONTROL OR MODERATE USE: Efforts to
modify internet use are attempted many times without success.
• Jill feels like a slave to Facebook, so she periodically swears off it
and deletes her account. This lasts for 2 days at most, then she
reactivates her account and returns to constantly checking it.
• Steve promises his parents he is not addicted to the Internet
or video gaming and that he can quit anytime. Weeks go by and
he has not been able to reduce his use.
Signs and Symptoms: Previously
Enjoyed Activities Are Abandoned
PREVIOUSLY ENJOYED ACTIVITES ARE ABANDONED:
as a result of excessive Internet or video game use, creative
or intellectual interests, recreational or social activities are
decreased or abandoned.
• Rather than socializing with her college friends or attending
classes, Suzanne stays in her apartment each day playing
online role play games.
• Marty is on academic probation for dropping out of numerous
college classes. Before he was involved in online poker, he
enjoyed his academic coursework and held a high GPA.
Signs and Symptoms:
Problem Avoidance
PROBLEM AVOIDANCE: Internet use or video game play
is seen as a way to escape problems or to gain relief from
negative feelings.
• Sonny would rather play video games than think about the
stress he feels when he anticipates his parent’s response to
his failing grades.
• Cassandra spends the evening online to get away from the
verbal abuse she is experiencing in her relationship.
• When Glenn is not playing video games or surfing the net,
he feels suicidal.
Signs and Symptoms:
Psychosocial Impairment
PSYCHOSOCIAL IMPAIRMENT: everyday life and social
functioning are impaired (e.g. in social, academic and work
arenas, as well as with personal hygiene and general self-care).
• John skips his college classes so he can play video games in
his dorm room.
• Carrie calls her boss at work claiming she is “sick” after staying
up all night engaged in sex-chat.
• Barry hasn’t showered or brushed his teeth for weeks. Except
for the few hours he sleeps (randomly), he is glued to his
computer screen.
• Cathy has grown agoraphobic. She now orders in pizza or
Chinese food rather than go out to shop. Her friends have
stopped contacting her, as she never returns their calls.
Similarities and Differences
with Other Addictions
• Video game addiction often starts in early childhood;
chemical addiction often starts in the teen years or
later
• The personalities of Internet addicts are usually
dependent, “schizo” (socially avoidant), passive,
desiring to remain in a child-like state; chemical
addicts are often more sociable, sexually active,
aggressive, “street-wise”, skilled in dealing with the
external world
• Both fail to cope well with problems and pain
• The progress of the disease for both can lead to
unmanageability and, eventually, even to death
Who Is Vulnerable?
• The young
• Those who are bored or lonely
• Those with ADD and Autism Spectrum Disorder
• Those with PTSD
• Any addict
• Those with negative family relationships
Potentially Harmful Impacts
on Child Development
Social Intelligence
• Necessity for Limbic Resonance: What is it?
and why do we need it?
• Attachment Needs
• Effective Communication of Thoughts,
Feelings and Needs
• External Boundaries
• Learning to Read Social Cues
• Handling Conflict
• Cooperation/Competition
• Aggression (cyber bullying, etc.)
Potentially Harmful Impacts
on Child Development
Sexual
• The development of the Sexual Template
• Intimacy Disorder and Sexual addiction
• The problems with pornography:
 Distortion of the sexual template
 Separation of sexual and emotional intimacy
 Unrealistic expectations
 Participation in a morally bankrupt industry
Potentially Harmful Impacts
on Child Development
Physical
• Sleep deprivation
• Lack of exercise, leading to poor posture,
underdevelopment of musculature, weight
problems, lack of desire for exercise
• Poor nutrition
• Eye, back and tendon strains
• Effect of heat on testes
• Effect of radiation
Potentially Harmful Impacts
on Child Development
Intellectual/Creative
• Attention/Focus
• Imagination/Creativity
• Resourcefulness/Common Sense
• Limited opportunities to learn from real life
• Wisdom/ Introspection
• Reduced learning due to stress and lack of sleep
• Persistence and ability to delay gratification
Potentially Harmful Impacts
on Child Development
Emotional Health
• Emotional Intelligence (in touch with emotions,
able to communicate, use and handle them
appropriately)
• Self-Soothing
• Frustration Tolerance
• Confidence and Self Esteem based on Reality
• Resourcefulness
• Strong Sense of Self
• Shame vs. Feeling Loveable
Potentially Harmful Impacts
on Child Development
Moral Compass
 Lack of moral guidance or modeling
 Reduced Empathy
 Violence, Intimidation
 Sexual Exploitation
 Greed/Consumerism
 Deceit, Manipulation
Potentially Harmful Impacts
on Child Development
Disengagement from
the Real World
•
•
•
•
•
•
•
Nature
Community
Family
Friends
Politics
Work
The Future
Challenges for Families
 Parent(s) away from home for long hours
 Parent(s) exhausted when home, emotionally
unavailable
 Parents who are, themselves, overusing digital
devices
 Lack of afterschool programs/extended family help
 Lack of financial resources
 Ignorance regarding child development, the Internet
and digital technology
 Codependency / Addiction / Mental Illness
 DV, abuse and/or neglect
Social Systems that Affect the
Development of IAD
• Lack of Official Recognition of IAD
• Lack of Public Education, reinforcing societal Denial
• Pressure from those industries that make money
from those who are addicted to various aspects of
the Internet (e.g. pornographers, game companies,
social network advertisers)
• Lack of affordable, available after-school activities
• Loss of family time due to overworked parents,
single parents
• Lack of an (affordable) mental health system with
practitioners who understand how to treat IAD
• A culture that admires and idealizes all things digital
Co-Occurring Disorders
(which came first?)
•
Sex Addiction/Intimacy Disorder
•
Asperger’s Syndrome
•
ADD/ADHD
•
Depression
•
Anxiety
•
PTSD
•
Other Addictions
•
Bipolar Disorder
•
Etc.
Challenges,
Interventions,
&
Modalities
Ways Around Controls
• Minimize screen using “Alt-tab” when someone
approaches the computer
• Use cellular broadband on PC by purchasing a
3G connection device
• Buy personal router and keep it hidden away
• Make a virtual drive within the operating system
(OS)
• Load the OS on an external drive
• Get up after everyone has gone to bed and
continue using
• Process data on the server side, and stream to
client device (computer or phone )
Challenges for Therapists
 Lack of training about IAD
 Lack of resources, like 12-steps for IAD
 Use of the Internet and video games is
culturally sanctioned, admired, required,
ubiquitous, and
allowed from earliest ages
 Lack of self awareness/denial about own use
 All of the above make this a very difficult addiction
to treat
Interventions to Bring In the Addict
Interventions to Bring In the Addict
•
Work with Parents/Spouses to create a
“false bottom”
•
Get assistance from an Educational Consultant
•
Formal interventions (breaking through denial)
Interventions:
Working with Parents/Spouses to create a
“false bottom” through
the realignment of family power
•
Break the Conspiracy-of-Silence
•
Send a message of Tough Love (develop “Deal Breakers”)
•
Coordinate care with knowledgeable professionals
•
Make decisions for the greater good of the Family
•
Help the family be consistent in holding sensible
boundaries
Abstinence versus Harm Reduction
Abstinence
• The quickest path through withdrawal
• Abstinence from all computer use or
just addictive applications?
• Easier with children than most adults
• Allows time for thinking about lessons to be
learned once client is through withdrawal
Copyright 2010 reSTART Internet Addiction Recovery Program, LLC
Abstinence versus Harm Reduction
Harm Reduction
• Requires buy-in from an adult addict
• Ideally, limited use follows a period of
abstinence
• Society requires computer use
• Risky and difficult. Prepare for relapse
• Strong support needed
Preparing for Withdrawal Symptoms
Preparing for Withdrawal Symptoms
• Physical
• Psychological
• Behavioral
• Create a safety plan (police, hospital, etc.)
• Self-soothing/soothing environment
• Prepare both client and family
Assessment
•
Complete Bio/Psycho/Social
•
Keep reassessing
•
Review medications
•
Assess for co-morbid conditions
•
Use multiple tools for assessment
reSTART: Internet Addiction
Recovery Program
• Residential treatment for Internet and video
game addiction
• Intensive Residential Program (45-90 days)
• Aftercare/transition to independent living
1. Intensive off-site
2. Sustainability
3. Affiliate
4. Alumnae
5. ITAA
reSTART: Internet Addiction
Recovery Program
• Family component at reSTART
• Parent coaching
• Impact letters
• Boundary letters
• Family weekend
South Korean Model
• South Korea
• Government funding for Public Education, research
and treatment (hospital and residential camps)
• Korean game companies help pay for treatment
• Camps are 2 weeks followed by 6 months of
individual and family therapy
• Children are screened in school starting at age 10
• Government provides books on IAD vs. healthy
computer use to teachers, students, parents and
counselors
Chinese Model
• Boot camps for 13-35 yr olds
• Some Western-style psychotherapy (mainly group
and family counseling)
• Private pay
• Indefinite stay
Outpatient Modalities
• No More Secrets
• Individual therapy
• Children
• Adults
• Family therapy
• Couples therapy
• Group therapy
• Psycho-Education
• Skills training
No More Secrets
• Out-patient Treatment for Sex/Love addiction
• Individual and group therapy for both man and
partner
• 2 or more 12-step meetings per week plus step
work with a sponsor
• Abstinence from bottom line behaviors
• Partner is encouraged to follow a parallel course
• Disclosure, cost and empathy letters come
before couples work begins
• Sexual fasting and therapeutic separation
Couples and Family Therapy
•
Help the marital relationship
•
Improve the parent/child bond
•
Improve family communication
•
Teach good parenting skills
•
Writing three letters
Group Therapy
•
Ends isolation
•
Offers support
•
Provides insight
•
Accountability from others
•
Develops intimacy skills
Copyright 2010 reSTART Internet Addiction Recovery Program, LLC
Psycho-education for the Addict
• What is addiction?
•
Cost/Benefit analysis of the addictive behavior
•
Bottom lines and top lines
•
Defining lapse and relapse
•
Building a support system
•
Triggers and safe coping strategies
•
Identifying strengths
•
Identifying life goals and making a plan
Family Psycho-Education
• How computers affect child development
• IAD and family dynamics
• Understanding addiction
• Neurobiology
• Signs and symptoms
• Defining lapse and relapse
• What needs are being served by the
addictive behavior?
Family Psycho-Ed (cont.)
 Importance of Parental Modeling of
appropriate behavior
 The Nature of Codependency
Rules for Adults
•
No more than 2 hrs of personal, digital and
internet-based activity per day (includes
phones, laptops, desktops, video games
devices, etc.) will help ensure an addiction
does not develop.
•
Work off-line whenever possible.
•
Set your digital devices so they will not alert
you when a new email or text message arrives.
Set specific time aside to check for messages.
Rules for Adults
•
Keep your phone off as much as possible.
When on, only answer calls that require answering
in that moment. Again, set specific time aside to
check voice messages and return calls.
•
Put boundaries around your work. It is
important to not be always working or available to
work.
Rules for Adults
•
Maintain home for yourself and your family.
Turn off your phone. Don’t migrate over to your
computer. If you absolutely must work from home,
designate a time and place for this to happen. If
you are going to go online for personal activity,
make sure you’ve put the health and
relationship needs of your family and yourself
first.
•
Turn off your phone when you sleep, unless
there is some absolute necessity otherwise.
•
Make sure you and your family are getting the 8
or more hours needed for sleep.
Age-Appropriate Boundaries
for Kids’ Screen Time
No screens in the bedroom
 Age 0-2, no screen time
 Age 2-7, 0-2 hrs of non-computer screen time
 Age 7-12, 1-2 hrs of screen time
 Age 13 and older, 2-3 hrs of screen time
 Internet, texting, and gaming well monitored
 No console video games before age 7
 Internet games only if showing maturity (HS age)
 Smart phone only after age 16 and with maturity.
Skills Training
• Social/Communication/Intimacy
• Stress Management/ Emotion Regulation
• Life Skills (cooking, cleaning, finances, etc.)
• Nutrition
• Fitness
Individual Therapy
• Motivational Interviewing (dealing with Resistance)
• RET/CBT/DBT
• Voice Dialogue
• Play Therapy
• Art Therapy
• Animal-Facilitated Therapy
• Etc.
Animal-Facilitated Therapy
 Picture of Ben and Animals
High Potential for Relapse
Recovery Planning
•
Success requires team work (client, therapist,
family, etc.)
•
Develop an Accountability Plan, with Monitoring
•
Contingency Planning in case of relapse
(time is of the essence)
•
Recovery Buddies
•
Healthy life-style/life goals
Relapse
• The difference between a Lapse and a Relapse.
• Contingency planning in case of lapse/relapse
• Reinvestigate boundaries and accountability system
• When/where is the lapse/relapse occurring?
• Time for drastic measures?
(no computer, in-patient, etc.)
Copyright 2010 reSTART Internet Addiction Recovery Program, LLC
Adjunctive Help
• Any activity which builds social relationships,
confidence, skills and self-esteem
• 12-step meetings (SLAA, ITAA, etc.)
• Meditation
• Medication
• 3rd party monitoring (accountability)
Adjunctive Help:
Computer Hardware and Software
•
PC Moderator
•
Spector-Soft (e-blaster)
•
TimesUpKidz
•
Parental controls
•
Mobile Apps
Recap
and
Q &A