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