Intervention for Pathological and Deviant Behavior Within an On-Line Community

Research into effective techniques for the treatment of Internet addiction.

Abstract

Treatment for Internet addiction is limited as this is a relatively new and often unrecognized affliction. Individuals complain that they have been unsuccessful in finding knowledgeable professionals or support groups specializing in Internet addiction recovery. Given these limitations, an experimental on-line consultation service was developed for pathological and deviant behavior among Internet users. The primary goals of the service were to serve as an informational resource, to provide immediate access to knowledgeable professionals, to administer brief, focused interventions designed to control and moderate Internet use, and to assist in seeking further treatment when required. This paper will review various on-line interventions and discuss the efficacy and limitations of an on-line consultation for this client population.

Introduction

The Internet has been touted as a revolutionary technology among politicians, academicians, and businessmen. However, among a small but growing body of research, the term addiction has extended into the psychiatric lexicon that identifies problematic Internet use associated with significant social, psychological, and occupational impairment (Brenner, 1996; Egger, 1996; Griffiths, 1997; Loytsker & Aiello, 1997; Morahan-Martin, 1997; Thompson, 1996; Scherer, 1997; Young, 1996a; 1996b; 1997a; 1997b;1998).

This research has primarily focused on assessment and evaluation of the extent of the addictive use of the Internet. Of all the diagnoses referenced in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV; American Psychiatric Association, 1995), Young (1996a) viewed Pathological Gambling as most akin to the pathological nature of Internet use and defined this as an impulse-control disorder which does not involve an intoxicant. An eight-item questionnaire which modified criteria for pathological gambling was developed to serve as a screening instrument to classify subjects as "dependent" or "non-dependent" users (See Appendix 1). It should be noted that while this scale provides a workable measure of Internet addiction, further study is needed to determine its construct validity and clinical utility. Survey results documented 396 case studies who experienced significant job, family, academic and financial problems subsequent to heavy patterns of chat room, newsgroup, and Multi-User Dungeon (i.e., on-line games) use.

Subsequent research on compulsive Internet use which used on-line survey methods showed that self proclaimed "addicted" users often looked forward their next net session, felt nervous when off-line, lied about their on-line use, easily lost track of time, and felt the Internet caused problems in their jobs, finances, and socially (e.g., Brenner, 1996; Egger, 1996; Thompson, 1996). Two campus-wide surveys conducted at the University of Texas at Austin (Scherer, 1997) and Bryant College (Morahan-Martin, 1997) have further documented that pathological Internet use is problematic for academic performance and relationship functioning using independent criteria for assessment.

Despite the increased awareness that pathological Internet use is a legitimate concern, treatment programs that address Internet addiction are only slowly beginning to emerge. Individuals who suffer from this have frequently complained that they have been unsuccessful in finding knowledgeable professionals or support groups specializing in Internet addiction recovery as this is still a relatively new and often unrecognized affliction. Therefore, an experimental on-line consultation service was developed in order to address pathological and deviant behavior among Internet users. The primary goals of the service were to serve as an informational resource, to provide immediate access to knowledgeable professionals, to administer brief, focused interventions designed to control and moderate Internet use, and to assist in seeking further treatment when required.

Methods

Serving as subjects were individuals who responded to an experimental on-line consultation service established at the web site for The Center for On-Line Addiction. Participants seeking on-line consultation initially completed a general assessment instrument designed to evaluate information related to pathological Internet use. This assessment form existed on a secured server in an effort to protect confidential information electronically transmitted. The assessment form included questions related to the presenting problem, level of Internet usage, prior clinical history, and demographic information. The main issue or specific nature of the presenting problem such as onset, frequency, and severity was initially assessed. Level of Internet usage was determined by examining the number of hours spent on-line per week (for non-academic or job-related purposes), the length of time using the Internet, and types of applications utilized. Prior clinical history was evaluated by asking relevant questions about prior addiction or psychiatric illness (e.g., depression, bipolar disorder, attention deficit disorder, obsessive-compulsive disorder). Completed forms were submitted directly to the principle investigator's electronic mailbox for a consult that were answered within 48 hours.

Findings and Discussion

Traditional abstinence models of addiction are not practical interventions as Internet use has several academic and professional benefits. The focus of treatment should consist of moderation and controlled use (Young, in press). In this relatively new field, outcome studies are not yet available. However, based upon individual practitioners who have seen Internet addicted subjects and prior research findings with other addictions, several techniques to treat Internet addiction have been developed: (a) practice the opposite time in Internet use, (b) employ external stoppers, (c) set goals, (d) abstain from a particular application, (e) use reminder cards, (f) develop a personal inventory, and (g) enter individual therapy or a support group. The list is not comprehensive, but address the major interventions utilized within the experimental on-line consultation service.

The first three interventions presented are simple time management techniques. However, more aggressive intervention is required when time management alone will not correct pathological Internet use (Young, in press). In these cases, the focus of treatment should be to assist the subject in developing effective coping strategies in order to change the addictive behavior through personal empowerment and proper support systems. If the subject finds positive ways of coping, then reliance upon the Internet to weather frustrations should no longer be necessary. However, keep in mind that in the early days of recovery, the subject will most likely experience a loss and miss being on-line for frequent periods of time. This is normal and should be expected. After all, for most subjects who derive a great source of pleasure from the Internet, living without it being a central part of one's life can be a very difficult adjustment.

Practice the Opposite

A reorganization of how one's time is managed is a major element in the treatment of the Internet addict. Therefore, the clinician should take a few minutes with the subject to consider current habits of using the Internet. The clinician should ask the subject, (a) What days of the week do you typically log on-line? (b) What time of day do you usually begin? (c) How long do you stay on during a typical session? and (d) Where do you usually use the computer? Once the clinician has evaluated the specific nature of the subject's Internet use, it is necessary to construct a new schedule with the client.

Young (1998) refers to this as practicing the opposite. The goal of this exercise is to have subjects disrupt their normal routine and readapt new time patterns of use in an effort to break the on-line habit. For example, let's say the subject's Internet habit involves checking E-mail the first thing in the morning. Suggest that the subject take a shower or start breakfast first instead of logging on. Or, perhaps the subject only uses the Internet at night, and has an established pattern of coming home and sitting in front of the computer for the remainder of the evening. The clinician might suggest to the subject to wait until after dinner and the news before logging on. If he uses it every weeknight, have him wait until the weekend, or if she is an all-weekend user, have her shift to just weekdays. If the subject never takes breaks, tell him or her to take one each half hour. If the subject only uses the computer in the den, have him or her move it to the bedroom.

This approach worked for Blaine, a forty eight-year-old school administrator, whose main problem had been staying on-line so long in the morning he would arrive hours late for work. Now he skips his morning on-line session and waits until evening to log on. "It was hard to change at first, almost like giving up my coffee in the morning," he relates. "But after a few days of struggling not to turn on the computer in the morning, I managed to get the hang of it. Now that I wait until evening to read my e-mail form friends, I get to work on time."

External Stoppers

Chris is an eighteen year old who discovered inter-rely chat when he received his Internet account at college. In high school, he was a straight "A" student, but his first semester grade point average was 1.8 due to his 60 hour a week on-line habit. He wrote, "I don't know what to do. I get so lost when on-line, that I forget how long I have been on. How can I control my time?" Unlike television, the Internet doesn't have commercial breaks (Young, 1998). Therefore, it is often useful to use concrete things that the subject needs to do or places to go as prompters to help log off. If the subject has to leave for work at 7:30 am, have him or her log in at 6:30, leaving exactly one hour before its time to quit. The danger in this is the subject may ignore such natural alarms. If so, a real alarm clock or egg timer may help. Determine a time that the subject will end the Internet session and preset the alarm and tell the subject to keep it near the computer. When it sounds, it is time to log off. In Chris's case, the application of external stoppers helped him to reduce his 12 hour on-line sessions to 4 hours, which left ample time for completion of assignments and homework for school.

Setting Goals

Many attempts to limit Internet usage fail because the user relies on an ambiguous plan to trim the hours without determining when those remaining on-line slots will come (Young, 1998). In order to avoid relapse, structured sessions should be programmed for the subject by setting reasonable goals, perhaps 20 hours instead of a current 40. Then, schedule those twenty hours in specific time slots and write them onto a calendar or weekly planner. The subject should keep the Internet sessions brief but frequent. This will help avoid cravings and withdrawal. As an example of a 20-hour schedule, the subject might plan to use the Internet from 8 to 10 p.m. every weeknight, and 1 to 6 on Saturday and Sunday. Or a new 10-hour schedule might include two weeknight sessions from 8:00 - 11:00 p.m., and an 8:30 am - 12:30 p.m. treat on Saturday. Incorporating a tangible schedule of Internet usage will give the subject a sense of being in control, rather than allowing the Internet to take control (Young, 1998).

Bill was a busy corporate marketing executive who found himself spending every evening on-line, and ignoring his wife and two children. He belonged to over 50 newsgroups and read through over 250 E-mails per day. Bill had no significant clinical history, but found himself immersed with newsgroups. He lamented, "My wife complains constantly and my children are always angry with me because I prefer the computer to spending time with them." Bill was very receptive to goal setting and planned his on-line sessions every week. He limited the number of newsgroups from 50 to 25, choosing only the most salient ones. He implemented a specific, time-limited schedule coupled with external stoppers such as an alarm clock to control his on-line habit and make time for his family.

Abstinence

Young (1996a) suggested that a particular application such as chat rooms, interactive games, newsgroups, or the World Wide Web may be the most problematic for the subject. If a specific application has been identified and moderation of it has failed, then abstinence from that application may be the next appropriate intervention. The subject must stop all activity surrounding that application. This does not mean that subjects can not engage in other applications which they find to be less appealing or those with a legitimate use. A subject who finds chat rooms addictive, may need to abstain from them. However, this same subject may use e-mail or surf the World Wide Web to make airline reservations or shop for a new car. Another example may be a subject who finds the World Wide Web addictive and may need to abstain from it. However, this same subject may be able to scan newsgroups related to topics of interest about politics, religion, or current events.

Abstinence is most applicable for the subject who also has a history of a prior addiction such as alcoholism or drug use. Marcia is a 39 year old controller for a major corporation. She had a ten year problem with alcoholism before she entered a local AA support group. While in her first year of recovery, she began to use the Internet to help with her home finances. Initially, Marcia spent a total of 15 hours per week using electronic mail and finding potential stock information on the World-Wide-Web. Until she discovered chat rooms, then her on-line time jumped dramatically to an estimated 60 to 70 hours per week as she chatted and routinely engaged in cybersex. As soon as she came home from work, Marcia rushed to her computer and stayed there the rest of evening. Marcia often forgot to eat dinner, called in sick to work to spend the day on-line, and took caffeine bills to help keep her alert and awake to indulge in her Internet habit. Her on-line habit had impaired her sleep patterns, health, job performance, and familial relationships. Marcia explained, "I have an addictive personality and do everything to excess, but at least being addicted to the Internet is better than being an alcoholic. I fear if I gave up the Internet I would begin drinking again." In this case, chat rooms were the trigger for Marcia's compulsive behavior. The focus of treatment for Marcia included abstinence from chat rooms with the continuance of using the Internet for productive purposes.

Subjects with a premorbid history of alcohol or drug addiction often find the Internet a physically "safe" substitute addiction as Marcia's case illustrates. Therefore, the subject becomes obsessed with Internet use as a way to avoid relapse in drinking or drug use. However, while the subject justifies the Internet is a "safe" addiction, he or she still avoids dealing with the compulsive personality or the unpleasant situation triggering the addictive behavior. In these cases, subjects may feel more comfortable working towards an abstinence goal as their prior recovery involved this model. Incorporating past strategies that have been successful for these subjects will enable them to effectively manage the Internet so that they can concentrate on their underlying problems.

Reminder Cards

Often subjects feel overwhelmed because, through errors in their thinking, they exaggerate their difficulties and minimize the possibility of corrective action (Young, 1998). To help the subject stay focused on the goal of either reduced use or abstinence from a particular application, have the subject make a list of the, (a) five major problems caused by addiction to the Internet, and (b) five major benefits for cutting down Internet use or abstaining from a particular application. Some problems might be listed such as lost time with one's spouse, arguments at home, problems at work, or poor grades. Some benefits might be, spending more time with one's spouse, more time to see real life friends, no more arguments at home, improved productivity at work, or improved grades.

Next, have the subject transfer the two lists onto a 3x5 index card and have the subject keep it in a pants or coat pocket, purse, or wallet. Instruct subjects to take out the index card as a reminder of what they want to avoid and what they want to do for themselves when they hit a choice point when they would be tempted to use the Internet instead of doing something more productive or healthy. Have subjects take the index card out several times a week to reflect on the problems caused by their Internet overuse and the benefits obtained by controlling their use as a means to increase their motivation at moments of decision compelling on-line use. Reassure subjects that it is well worth it to make their decision list as broad and all-encompassing as possible, and to be as honest as possible. This kind of clear-minded assessment of consequences is a valuable skill to learn, one that subjects will need later, after they have cut down or quite the Internet, for relapse prevention.

Marcia, who we discussed earlier, utilized a reminder card to help abstain from chat rooms. She attached the card to her computer to help fight her cravings. Her list of problems included: risked loss of job, hurting her mother and children who hardly spoke with, lost sleep, and an increase in catching viral infections. Her list of benefits included: improved work performance, better relationships with her family, increased sleep, and enhanced health.

Personal Inventory

Whether the subject is trying to cut down or abstain from a particular application, it is a good time to help the subject cultivate an alternative activity. The clinician should have the subject take a personal inventory of what he or she has cut down on, or cut out, because of the time spent on the Internet. Perhaps the subject is spending less time hiking, golfing, fishing, camping, or dating. Maybe they have stopped going to ball games or visiting the zoo, or volunteering at church. Perhaps it is an activity that the subject has always put off trying, like joining a fitness center or put off calling an old friend to arrange to have lunch. The clinician should instruct the subject to make a list of every activity or practice that has been neglected or curtailed since the on-line habit emerged. Now have the subject rank each one on the following scale: 1 - Very Important, 2 - Important, or 3 - Not Very Important. In rating this lost activity, have the subject genuinely reflect how life was before the Internet. In particular, examine the "Very Important" ranked activities. Ask the subject how these activities improved the quality of his or her life. This exercise will help the subject become more aware of the choices he or she has made regarding the Internet and rekindle lost activities once enjoyed. This technique was utilized with most of the on-line subjects and appeared particularly helpful for those who felt euphoric when engaged in on-line activity by cultivating pleasant feelings about real life activities and reduced their need to find emotional fulfillment on-line.

Individual Therapy and Support Groups

Obviously, the limited availability of support groups or specialists in Internet addiction recovery is the major impetus for seeking on-line consultation. It is important to also keep in mind that in many cases, on-line consultation is not intended to face-to-face therapy and further treatment is recommended. Therefore, a large part of the on-line service is to assist subjects in locating drug and alcohol rehabilitation centers, 12 Step recovery programs, or therapists who offer recovery support groups that will include those addicted to the Internet. This outlet will be especially useful for the Internet addict who has turned to the Internet in order to overcome feelings of inadequacy and low self-esteem. Further treatment, especially recovery groups, will address the maladaptive cognitions leading to such feelings and provide an opportunity to build real life relationships that will release their social inhibitions and need for Internet companionship. Lastly, these groups may help the Internet addict to find real life support to cope with difficult transitions during recovery akin to AA sponsors.

Some subjects may be driven towards addictive use of the Internet due to a lack of real life social support. Young (1997b) found that on-line social support greatly contributed to addictive behaviors among those who lived lonely lifestyles such as homemakers, singles, the disabled, or the retired. This study found that these individuals spent long periods of time home alone turning to interactive on-line applications such as chat rooms as a substitute for the lack of real life social support. Furthermore, subjects who recently experienced situations such as a death of a loved one, a divorce, or a job loss may respond to the Internet as a mental distraction from their real life problems (Young, 1997b). Their absorption in the on-line world temporarily makes such problems fade into the background. If the on-line assessment uncovers the presence of such maladaptive or unpleasant situations, treatment should focus on improving the subject's real life social support network.

The clinician should help the client find an appropriate support group that best addresses his or her situation. Support groups tailored to the subject's particular life situation will enhance the subject's ability to make friends who are in a similar situation and decrease their dependence upon on-line cohorts. If a subject leads one of the above mentioned "lonely lifestyles" then perhaps the subject may join a local interpersonal growth group, a singles group, ceramics class, a bowling league, or church group to help meet new people. If another subject is recently widowed, then a bereavement support group may be best. If another subject is recently divorced, then a divorcees support group may be best. Once these individuals have found real life relationships they may rely less upon the Internet for the comfort and understanding missing in their real lives.

Summary

On-line consultation may be beneficial in the provision of prevention, education, and short-term intervention for pathological Internet use. However, as these cases are based on limited and experimental data, additional research is necessary to explore the exact utility of such an on-line consultation service. The systematic comparison between E-mail, chat room dialogue, and in vivo interventions within an on-line community should be considered. Its utility as an adjunct to face-to-face therapy should also be assessed. Finally, on-line interventions with any patient population holds significant ethical and therapeutic limitations that need to be considered.

While there may be promise for on-line consultation services, many will question its utility for those addicted to the Internet. The common argument is "Isn't it like holding an AA meeting at a bar." It is important to keep in mind that Internet addicts and their families often complain that they have been unsuccessful in finding local treatment programs, support groups, or individual therapists who are familiar with this problem. Since this is a relatively new and unrecognized affliction, many therapists minimize the impact the Internet has on an individual and therefore do not address this issue as part of the treatment. Therefore, an on-line service provides access to knowledgeable professionals available independent of geographic limitations. Additionally, on-line interventions are not intended to reinforce habitual use, but rather focus on moderated and controlled Internet use.

With the rapid expansion of the Internet into previously remote markets and another estimated 11.7 million planning to go on-line in the next year (IntelliQuest, 1997), the Internet may pose a potential clinical threat little is understood about the treatment implications for this emergent familial and societal problem. Future research may address specific interventions and conduct outcome studies for effective treatment management. Finally, future research should focus on the prevalence, incidence, and the role of this type of behavior in other established addictions (e.g., substance dependencies or pathological gambling) or psychiatric disorders (e.g., depression, bipolar disorder, obsessive-compulsive disorder).

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