Cognitive-Behavioral Approaches to Outpatient Treatment of Internet Addiction in Children and Adolescents Daniel L. King,1 Paul H. Delfabbro,1 Mark D. Griffiths,2 and Michael Gradisar3 1 The University of Adelaide Nottingham Trent University 3 Flinders University 2 Excessive and potentially addictive use of the Internet among children and adolescents has emerged as a major concern in recent times. Internet addiction is often conceptualized as an impulse control disorder, with features similar to pathological gambling. However, there remains considerable debate about the core components, etiological processes, course, and maintaining factors of the disorder. This article presents a case study of a 16-year-old male with generalized pathological Internet use. Critical issues relevant to case conceptualization, assessment, and choice of therapy are examined. Although the evidence base is limited in this emerging area of clinical psychology, we provide a summary of C 2012 Wiley Periodicals, empirically supported cognitive-behavioral techniques for Internet addiction. Inc. J. Clin. Psychol: In Session 68:1185–1195, 2012. Keywords: Internet addiction; cognitive-behavioral therapy; treatment; adolescence Introduction Over the last decade, the number and quality of research studies on Internet addiction have steadily increased, in parallel to the burgeoning popularity of the Internet itself. The proposed but as yet unrecognized disorder now has a presence within a range of peer-reviewed journals covering specialist areas including (but not limited to) clinical, social, cognitive, developmental, health, and organizational branches of psychology. Internet addiction disorder is often conceptualized as an impulse control disorder (Sim, Gentile, Bricolo, Serpollini, & Gulamoydeen, 2012), with features of its clinical presentation similar to pathological gambling. Internet addiction is thought to comprise several subtypes, including cyber-sexual preoccupations, online video gaming, gambling, shopping, browsing, emailing, and social networking (Block, 2008). However, there remains considerable debate about the core components, etiological processes, course, and maintaining factors of the disorder (Griffiths, 2008; Turner, 2008; Wood, 2008). Given this variability in the definition and methods of assessment of Internet addiction, it is not surprising that estimated prevalence rates of the disorder vary significantly, ranging from 0.3% to over 10% (King, Delfabbro, & Griffiths, 2012). Currently, there are no plans to include Internet addiction (or a similar diagnosis) within the spectrum of addictive disorders in the upcoming Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), but it may be noted within an appendix as being worthy of further empirical investigation. Interestingly, despite the prominence and ubiquity of the Internet in modern society, there have been only two proposed revisions to the current DSM specifically related to the Internet and/or online behavior. These revisions refer to the following disorders: (a) illness anxiety disorder (repeatedly seeking reassurance online about bodily signs of illness) and (b) hypersexual disorder (viewing and downloading of pornographic images and videos). Arguably, these revisions may be considered more easily accommodated by the existing nomenclature given their attachment to a pre-existing disorder and/or established body of knowledge. Please address correspondence to: Daniel L. King, School of Psychology, Level 4, Hughes Building, The University of Adelaide, Adelaide, SA 5005, Australia. E-mail: [email protected] C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(11), 1185–1195 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21918 1186 Journal of Clinical Psychology: In Session, November 2012 Proponents of an Internet addiction diagnosis appear to be road-blocked by the lack of a knowledge base demonstrating consistent findings. In particular, the lack of a common framework for Internet addiction has prevented a unified research effort, such that many published studies differ conceptually and methodologically. Side-by-side comparison of findings thus becomes difficult, if not impossible. Additionally, Blaszczynski (2006) has highlighted a specific need for evidence of impaired control and neuroadaptation processes associated with Internet addiction, rather than obtaining further evidence of the adverse consequences of prolonged Internet use. In sum, the Internet addiction field appears to be caught in a classic Catch-22 situation: Further empirical research is needed to establish its legitimacy, but lacking a standardized approach to assessment much research is often flawed in principle. In the last 15 years, there have been several proposals for standard diagnostic criteria for Internet addiction. For the most part, these definitions and/or conceptualizations of the disorder have been modelled (in part or entirely) on the DSM-IV criteria for pathological gambling, the DSM-IV criteria for substance dependence, the International Classification of Diseases 10th Revision (ICD-10) criteria for substance dependence, or a combination of these criteria. A recent review by Sim et al. (2012) has attempted to develop a common framework and criteria for Internet addiction. The authors reviewed over 40 published studies and concluded that the most valid and reliable way of conceptualising Internet addiction was using adapted DSMIV criteria for pathological gambling. Sim et al. claimed that these criteria were also suitable for classifying pathological “computer use” and “video gaming,” by substitution of the term “gambling.” Although scholarly agreement on this method of assessment would advance the field, it has been argued that there remains a need to distinguish between addictions on the Internet, and addictions to the Internet. For example, Griffiths (2008) argues most “Internet addicts” are not addicted to the Internet itself, but use it as a medium to fuel other addictions. In short, a gambling addict who uses the Internet to gamble is a gambling addict not an Internet addict (Blaszczynski, 2006). The Internet is just the place where they conduct their chosen (addictive) behavior. Clinicians should therefore be mindful of whether problematic behavior related to the Internet is in fact a client’s primary psychological problem, and not an unhelpful coping strategy or safety behavior arising from other psychopathology (e.g., social anxiety). While Internet use may still be relevant to case conceptualization and treatment in such cases, nonprimary problems related to the Internet may not be appropriately catered to by treatment techniques and approaches for addiction. Our intention thus far has been to orient the reader to the conceptual confusion facing both experts and relative newcomers in the emerging field of Internet addiction. This background information is useful to bear in mind when considering choice of assessment and therapy resources for clients with addictive tendencies on the Internet. The aim of this article is to present a case study of a young male Internet addict, as conceptualized by an accepted cognitivebehavioral therapy (CBT) model of Internet addiction (Davis, 2001). This case example is intended as a vehicle for discussion of assessment and treatment options for Internet addiction. As such, this paper will highlight what is (and what is not) currently known in this emerging clinical area, and will make a series of recommendations for clinicians. Case Illustration Presenting Problem and Client Description John is a 16-year-old male who lives at home with his two parents in Adelaide, South Australia. John spends up to 10 hours per day on the computer in his bedroom, browsing a variety of news and entertainment websites, chatting on online forums, playing online video games (including massively multiplayer online role playing games), and downloading movies, television shows, and music for personal use. John has been familiar with computer technology since he was a small child. However, he became more intensely engaged when he was gifted his own personal computer on his 13th birthday. John recalls vividly the excitement of owning his first computer and spending that day and most of the night learning its capabilities and going online. CBT Approaches 1187 John’s parents noticed the frequency of John’s computer activities steadily increased within a subsequent period of a few weeks. Initially, John’s preoccupation with the computer was dismissed as a temporary “phase.” However, it became apparent that John was using all available time at home on the computer. John’s parents attempted to reduce his computer time, using verbal commands/threats or removing the power cable. John’s parents became engaged in a cycle of removing and then restoring computer access to placate John’s frustrated complaints about being bored or being treated “unfairly.” Permitting John to use the computer on his terms was eventually seen as a way of avoiding confrontation and maintaining family harmony. In the past year, John’s parents have given up completely on restricting access and allowed the computer to be kept permanently in John’s bedroom. John regularly stays up late (i.e., 2 a.m.) engaging in online activities and has difficulty in waking for school. He often skips family gatherings to use his computer. Similarly, he has stopped attending after-school training for a local basketball team, leading to being dropped from the team. John’s mealtimes are irregular, and he often eats at his computer. He routinely sleeps in late on weekends. He consumes several caffeine drinks each day to stay up late using the computer and to help feel more alert in the morning. To avoid leaving his room to go to the bathroom, John urinates in plastic bottles stored under his desk. When not on his computer at home, John uses his mobile phone to maintain access to the Internet. He is often agitated in situations where access to the Internet is not available, but uses this time to think about and plan the next activity on his computer. Although John demonstrates a great deal of knowledge about the Internet and online activities, he has difficulty in describing procedurally how he spends his time online. He explains that, when online, he is often engaged in multiple tasks at once and will lose track of time. John admits that sometimes he forgets or cannot be bothered to do things due to spending time on the computer. John’s school attendance is irregular and he often skips afternoon classes. His school grades have declined significantly in the past year, and teachers have noted a lack of attention and concentration in class. John is considered intelligent but does not apply his natural ability to schoolwork. He neglects his homework, household chores, and personal hygiene. When he was 15 years old, he dated a girl at his school for a period of less than one month. The relationship ended when John repeatedly failed to show for gatherings organized by the girlfriend. John was playing video games at the time. John is not “popular” at his school, but does have one friend. Their interaction outside of school is usually spent online in chat programs or playing a competitive video game. John shows little interest in noncomputer-related activities and has not expressed any ambitions (e.g., career or travel) for adult life. Case Formulation As with any psychological disorder, the client’s history forms the most important basis for diagnosing Internet addiction. John reports a habit of engaging in a variety of nonessential online activities for between 35 to 70 hours per week in the past 12 months. Although research evidence suggests frequency of computer use is not a perfect indicator of problems, adolescent media use for nonhomework purposes in excess of 2 hours/day is likely to indicate adverse social and emotional consequences. Assessing how the Internet is used (i.e., the functional relationship between user and computer) generally offers a much better insight into risk of clinical problems (Young & de Abreu, 2011). For example, adolescents with addictive tendencies on the Internet tend to spend abnormally long periods of time engaged in solitary online activities (e.g., browsing or downloading), engaged in communication with strangers, and/or browsing sites with no clear purpose in mind. John’s first encounter with a computer at 13 years of age is noteworthy as an early critical event. John recalls first owning a computer as being personally significant (other life activities were instantly seen as less important) as well as emotionally gratifying (“exciting”). Theories of addiction typically describe an addict’s first encounter with their addictive object or activity of choice as an “aha!” moment, a moment of profound self-discovery. An addict may reflect, “Where has this been all my life?” Many adult pathological gamblers began their gambling 1188 Journal of Clinical Psychology: In Session, November 2012 Figure 1. Davis’ (2001) cognitive-behavioral model of PIU. career at an early age, and usually can recall experiencing a sizeable win that triggered automatic thoughts of self-efficacy (e.g., “I am successful” or “I am a winner”) as well as strong emotions. Similarly, many pathological online video gamers can recall the very first video game they played and having positive emotions associated with the rewards and/or challenge involved. Kouimtsidis, Reynolds, Drummond, Davis, and Tarrier (2007) explain that positive outcome expectancy beliefs–those beliefs that good things will happen when engaged in the addictive behavior (e.g., “I will feel better if I go online”)–are often formed in the early stages of addiction. Positive expectancy beliefs make it difficult to resist the addictive activity in high-risk situations (i.e., in the presence of Internet cues, social pressure to go online, or when feeling depressed or anxious). Some models of Internet addiction prioritize adverse consequences of prolonged Internet use. Because of this, some forms of excessive Internet use, although harmful, may be misclassified as an addiction. Davis’ (2001) model is useful in conceptualizing a client’s Internet use because it may determine whether such use is the client’s primary problem. The model places an emphasis on maladaptive cognitions underpinning pathological Internet use (PIU; i.e., Internet addiction), thus making it useful for CBT approaches to treatment. The model distinguishes two types of PIU. The first type is specific PIU, which refers to overuse of specific Internet functions, such as email, pornography, shopping, or gambling. Such addictive tendencies are assumed to occur in the absence of the Internet. The second type is generalized PIU, which refers to a general, multidimensional overuse of the Internet and includes wasting time online. John’s case indicates generalized PIU due to (a) his use of several different functions of the Internet, (b) his social isolation, and (c) procrastination and time-wasting tendencies (i.e., lack of a direct purpose of going online). It is likely that John’s problems may not have developed (or would not be as severe) in the absence of the Internet. Further applying the model (see Figure 1), John’s PIU is maintained by two core processes: distorted thoughts/thought processes and reinforcement. Problematic cognitions may refer to the self, others, or the world. Like depression, thoughts about the self that maintain PIU are generally characterized by negative self-evaluation, self-doubt, and low self-efficacy. For example, these thoughts may include “I am only good on the Internet,” “I am a worthless nobody when offline, but online I am important,” and “I am a failure in the real world.” Similarly, problematic Internet use is often maintained by negative evaluations and all-ornothing statements about the world, such as “The Internet is the only good place available to me” and “People in the real world always treat you badly.” Distorted thoughts are triggered whenever CBT Approaches 1189 the Internet or an associated stimulus is present. An early step in developing a conceptualization would be to identify automatic thoughts and processes when going online and those situations that precipitate Internet use. John’s online use is also maintained by the many rewarding aspects of the Internet. Reward features are less important in understanding the nature of PIU but can be useful in identifying “high-risk” aspects of the Internet (e.g., online games) that a client has particular difficulty in regulating use. The Internet offers many different types of reinforcers (e.g., new information, positive social feedback, points/rewards in a video game). Such rewards may be particularly salient for young people, such as John, who generally lack financial means and independence and for whom the Internet may represent a new world of freedom and possibility. As an individual spends more time online, less time is spent in real life activities. With fewer opportunities for reinforcement from nononline activities, the Internet becomes increasingly attractive and relied upon for gratification of needs. Over time, the user may disengage from activities in the real world completely or to the extent that normal involvement is no longer an available option. The 24/7 nature of the Internet then fills the void of extra time and unmet needs resulting from social exclusion and/or nonparticipation in normal activities. Using current assessment techniques (Beard, 2005; Griffiths, 2008; Shaw & Black, 2008) it is possible to assess the extent and severity of John’s presenting problem. Brief screening questions adapted from DSM-IV criteria for pathological gambling may be appropriate for this purpose. Using this approach revealed John meets at least 7 of the 10 criteria for Internet addiction, which were as follows (a) increasing preoccupation with the Internet, (b) spending more and more time on the Internet, (c) unsuccessful attempts to limit Internet use, (d) withdrawal symptoms when Internet use is reduced, (e) using the Internet as an escape, (f) neglect of household chores to spend more time on the Internet, and (g) poor school performance as a consequence of Internet use. Meeting five or more criteria in the past 12-month period indicates addiction. Additionally, John’s symptoms are not related to a manic episode or symptoms of Axis I disorders. Thus, according to this assessment method, John may be considered a generalized pathological Internet user. Course of Treatment Little is known about the effective course of CBT treatment for Internet addiction. Table 1 presents a summary of the published evidence base on treatment. Clinical interventions for Internet-related problems vary considerably, with a mixture of studies employing pharmacological treatment, cognitive-behavioral therapies, or self-devised interventions (Griffiths & Meredith, 2009; King, Delfabbro, Griffiths, & Gradisar, 2011; Shaw & Black, 2008). Specifically, there have been three studies that have employed CBT on its own or in conjunction with other treatment approaches (Du, Jiang, & Vance, 2010; Orzack, Voluse, Wolf, & Hennen, 2006; Young, 2007). Although this evidence base is not strong, there are promising early signs that CBT for a relatively short period (i.e., 8 to 12 sessions) may be successful in reducing both frequency of Internet use and symptoms of Internet addiction. Unfortunately, CBT treatments specifically developed for Internet addiction have not yet been manualized, and thus specifics of treatment protocol are not widely available. Du et al. (2010) have conducted the only randomized, controlled trial for the treatment of Internet addiction in adolescents. Their study involved a multimodal school-based intervention involving eight sessions of group-based CBT. Group size comprised 6–10 participants. Therapy involved addicted adolescents learning principles of effective communication with their parents; learning how to manage online relationships; techniques for controlling impulses; and techniques for recognizing and stopping problematic behavior. Parent training was also delivered in tandem, and this involved teaching parents to recognize their child’s emotions, increase problem solving and communication between family members, and develop techniques for managing adolescents with problem technology use. Psychoeducation was also delivered to teachers in the school. Posttreatment, adolescents significantly reduced their Internet use and anxiety and improved their time management skills. Treatment gains were maintained at 6-month follow-up. Beard’s Diagnostic Questionnaire Korean-Internet Addiction Scale Young Internet Addiction Scale; DSM-IV criteria for substance dependence Korean-Internet Addiction Scale Du et al. (2010) Han et al. (2009) Han et al. (2010) Orzack Time Intensity Scale Young Internet Addiction Scale Young Diagnostic Questionnaire Internet Addiction Test Orzack et al. (2006) Shek et al. (2009) Su et al. (2011) Young (2007) Kim (2008) Assessment Study 1. CBT (12 sessions) 1. Multi-modal counselling (15 to 19 months) 1. Self-help (3 types) 2. Control 1. Group counselling (5 weeks) 2. Control 1. CBT; Readiness to change; motivational interviewing (16 weeks) 1. Methylphenidate (8 weeks) 1. Bupropion (6 weeks) 2. Control 1. CBT (8 sessions) 2. Control Treatment Selected Characteristics of Treatment Studies for Internet Addiction Table 1 11–18 59 114 – – 26–59 35 65 – 17–29 19 25 8–12 12–17 Age (years) 62 56 N CBT reduced most clients’ thoughts and behaviors related to compulsive Internet use. Gains observed at 6-month follow-up. CBT reduced Internet overuse and associated symptoms, and improved time management skills. Treatment gains were observed at 6-month follow-up. Methylphenidate significantly reduced severity of addiction symptoms and overall Internet usage. Bupropion reduced cravings for online video game play, total game play time, and cue-induced brain activity. 10 counselling sessions reduced addiction symptoms and increased self-esteem, as compared with the control group. Group treatment increased quality of life and depressive symptoms, but did not reduce Internet misuse. Patients with co-morbid anxiety/mood disorder responded best to treatment, whereas ADHD clients showed no improvement. Counselling produced a decrease in IA symptoms. Participants reported high satisfaction with the program. All treatment groups showed significant decreases in online activity (hours) and YDQ scores after 1-month. The “expert system” treatments were the most effective. Outcome Cohen’s d = 0.72–0.82 (YDQ score); Cohen’s d = 0.75–0.98 (online activity) Not reported Not reported Not reported Not reported Not reported Cohen’s d = 1.08 (post) and 1.35 (6-month follow-up) Not reported Treatment effect size 1190 Journal of Clinical Psychology: In Session, November 2012 CBT Approaches 1191 Two studies employing CBT for adult Internet addicts suggest further techniques. In Young’s (2007) study, CBT involved clients monitoring their thoughts and identifying those that trigger addictive feelings and actions, as well as learning new coping skills and relapse prevention strategies. The initial stage of therapy was behavioral, focusing on specific behaviors and situations in which Internet addiction causes the most difficulty in the client’s life. In later stages of therapy, greater focus was placed on cognitive assumptions and distortions and their effect on behavior. In Orzack et al.’s (2006) study, a similar approach was employed. Participants were guided to identify and then modify maladaptive cognitions, develop a repertoire of coping strategies to deal with unpleasant emotional states, and engage in homework assignments. Motivational interviewing techniques were also used to help patients gain insights into the costs and benefits of their Internet use and develop problem-solving strategies to reach a goal of controlled Internet use. Interestingly, in Orzack et al.’s study, CBT was not effective in reducing Internet addiction symptoms but it did increase perceived quality of life and reduced depressive symptomology. Quality of design and reporting in Internet addiction treatment studies is not optimal. A review by King et al. (2011) evaluated clinical treatment studies for Internet-related problems using the Consolidating Standards of Reporting Trials (CONSORT) statement. The CONSORT statement is a recognized “gold standard” for assessing the reporting quality of clinical trials. King et al. reported that the majority of studies had several key limitations, including (a) inconsistencies in definition and diagnosis of problems, (b) a lack of randomization and blinding techniques, (c) a lack of adequate controls or other comparison groups, and (d) insufficient information concerning recruitment dates, sample characteristics, and treatment effect sizes. Despite these limitations, the field is moving in the right direction in developing a greater evidence base. The wide scope of Internet-related addictions (e.g., cyber-sexual addiction, compulsive browsing, and online gaming), as well as the variance in at-risk populations (as a function of, among other variables, age, educational background, and presence of comorbid disorders), necessitates further studies to tease out and target separately different types of users and problems. In coming years, the evidence base on CBT treatment for Internet addiction is expected to grow in response to client need. Internationally, a large number of individuals with Internetrelated problems have received some form of treatment from a mental health or medical service provider. In particular, there is significant demand for treatment for Internet-related problems in China, Taiwan, and South Korea, where the estimated prevalence of Internet addiction problems among adolescents is reportedly higher than in Western industrial countries. The South Korean government has reportedly established a network of over 150 counseling centers for treatment of Internet addiction and have introduced treatment programs at almost 100 hospitals (Kim, 2008). In addition, numerous boot camp style programs for Internet-addicted adolescents have emerged in both China and Korea (Koo et al., 2011). In Western countries, clinics specializing in the psychological treatment of computer-based addictions have also emerged: the Center for Online and Internet Addiction located in Bradford, Pennsylvania, United States; the Computer Addiction Study Center, at McLean Hospital, Belmont, Massachusetts, United States; the Broadway Lodge residential rehabilitation unit located in Somerset, England; and the Smith & Jones 12-step (Minnesota Model) clinic located in Amsterdam, Holland. Additionally, there are some online providers of treatment services for Internet addiction (e.g., netaddiction.com; netaddictionrecovery.com; onlineaddiction.com.au; techaddiction.ca), some of which are modelled on 12-step self-help treatment philosophies and offer books and resources for parents and teachers dealing with Internet-addicted adolescents. Outcome and Prognosis Available literature suggests that adolescent Internet addiction may be treated effectively using CBT approaches. Relatively short-term treatment (i.e., 3 to 6 months) may be adequate. John’s example highlighted above is quite severe, given his older age, intense pattern of Internet use, and DSM-IV symptom profile, but this is typical of many patients in clinical trials. Research evidence suggests that Internet addiction is not likely to remit spontaneously in adolescent populations; rather, an adolescent pathological adolescent user is highly likely to remain pathological 2 years 1192 Journal of Clinical Psychology: In Session, November 2012 later without an intervention. Internet addiction symptoms are also known to increase severity of Axis I symptomology, as well as interfere with effective treatment of these disorders. Evidence suggests comorbid attention deficit and hyperactivity disorders (ADHD) are likely to reduce effectiveness of CBT (Orzack et al., 2006); however, pharmacological treatment (i.e., methylphenidate) may be effective in reducing both ADHD and addiction symptoms in this client subgroup (Han et al., 2009). Engaging parents and teachers in the treatment process demonstrates good preliminary support. Prognosis of Internet addiction is currently not well understood given the lack of longitudinal studies and follow-up data in clinical trials. Clinical Practices and Summary The following clinical techniques with empirically supported utility may be drawn from treatment studies for adolescent Internet addiction: r r r r r r r An activity-monitoring schedule may be useful for a clinician and client to gain a shared understanding of what types of online activities occur (i.e., in a typical week), at baseline and over the course of therapy. It may also be useful for the client to document thoughts and emotional states before, during, and after online activities to understand the functional purpose of Internet use. Cognitions, emotions, and behavioral activity that occur in response and in tandem to the online behavior should also be recorded. For example, John should keep a log of those times when he fights with his parents about his computer use or urinates in a bottle at his computer. This information may be helpful for John to understand the negative effect of his excessive computer use, and motivate positive change. Treatment goals should be realistic given the pervasiveness of the Internet in school and home life. For example, abstinence from the Internet may not be possible, given its role in homework assignments, social life, and so on. Controlled or regulated Internet use is often the target goal in clinical studies (Shek, Tang, & Lo, 2009). John’s initial goal in therapy, therefore, may be to not use the Internet when doing his homework. Young (2007) suggests that behavior therapy (i.e., conditioning) may be used to relearn how to use the Internet to achieve specific outcomes, such as moderated online usage and, more specifically, abstinence from problematic online applications and controlled use for legitimate purposes. Behavior-based strategies to reduce prolonged Internet use may be useful in the beginning stages. For example, using an alarm clock to set a maximum limit of 45 minutes of Internet use, and then having to do something else for 15 minutes. Similarly, having the client wait for 5 minutes at the computer with the screen turned off before initiating use. Behavioral experiments to test problematic cognitions associated with Internet use (e.g., “I have no control over my Internet use”) or reduced online behavior (e.g., “I am worthless without the Internet in the life”) may help to build a client’s self-confidence. An example experiment may involve testing a belief about “uncontrollability” by having the client repeatedly open and close a favorite website without interacting with the website. Psychoeducation is an effective adjunct to CBT, particularly for an adolescent’s parental authorities. Many parents have limited knowledge of the Internet, its functions, and issues of cyber safety. Parents should also be informed that simply removing the computer from a heavy adolescent user’s life can be a significant shock and may be counterproductive to developing a trusting and supportive parent-child relationship (Dini, 2008). John’s parents’ attempts to reduce John’s Internet use by removing and restoring Internet access in the bedroom were not effective and created significant relationship discord. It would be helpful if they provided John with support and encouragement for his efforts in reaching his therapeutic goals. Working collaboratively with adolescent clients and their parents has been shown to improve parent-child communication and consolidate CBT practice. In most cases, an adolescent’s habitual Internet use is likely to have resulted in a breakdown in family communication and cause significant stress and conflict. Family relationships may be repaired by collaboratively reaching a shared understanding about what Internet addiction is and what it is not, having common goals for therapy, and setting time for bonding as a family. CBT Approaches r r r r r r r r 1193 Rowan (2001) presents the following Internet addiction prevention guidelines for parents with young children: (a) limit technology use to 1–2 hours per day, (b) exercise for 3–4 hours per day, (c) listen, hugs, bedtime stories, (d) removing TVs from bedrooms, no “tech dinners” Sundays and holidays, and (e) no technology at school recess. These may also be adapted as goals for therapeutic purposes. For example, it may be helpful for John to schedule meals (particularly dinner) in the dining room or somewhere in the house where he cannot use the Internet. John’s parents could use this “tech-free” time an opportunity for bonding. Sleep patterns are often disrupted as a result of prolonged Internet use. Clients may benefit from interventions aimed at establishing normal sleep/wake activity, particularly shifting electronic media use to during daylight hours (without necessarily restricting Internet hours) rather than directly before bed. Epidemiological studies of adolescent sleep suggest computer use prior to sleep is associated with extended time taken to fall asleep, poorer quality of sleep, and decreased daytime alertness and concentration. Improved sleep as a first step may aid in motivating engagement in other life areas. Motivational interviewing (MI) as an adjunct to CBT shows strong empirical support in field of addiction. MI may be used to (a) elicit self-motivational statements, (b) handle (i.e., “roll with”) client resistance to altering Internet use using reflection and summarizing techniques, (c) examine helpful and unhelpful aspects of Internet use, and (d) explore costs and benefits of changing Internet use in context of client’s values. Reminder cards (or “flashcards”) that summarize treatment goal(s) and/or list a self-motivational statement may be useful for a client to carry at all times. A client’s preoccupation with the Internet may be an obstacle to identifying alternative ways of spending time. The creation of a personal inventory of activities no longer engaged in since using the Internet may be useful. For adolescents without a history of other interests or hobbies, identifying new activities that cater to client strengths or competencies (e.g., teambased physical activity, arts/craft, volunteer work) could be explored. For John, this may involve joining a local basketball team. Distraction may be a useful tool for adolescent clients to help refocus attention from internal (emotional states, automatic thoughts) or external Internet-related stimuli. Cognitive distraction involves helping clients to focus their attention away from the Internet cues by focussing on other thoughts (Kouimtsidis et al., 2007). The goal is to improve regulation and control of attention. Examples may include focussing on relaxing or pleasant images or a memory of a positive event. The client should practice this skill so that he or she is easily able to switch attention to such thoughts in a high-risk situation. Although not always possible, a group setting may be helpful in normalizing adolescents’ feelings of shame, guilt, worthlessness, and isolation related to their Internet addiction symptoms. Group settings are often employed in treating addiction because they foster a supportive, nurturing, and non-judgmental environment needed for recovery. Young (2007) suggested that those who suffer from negative core beliefs may most attracted to the anonymity of the Internet to overcome perceived inadequacies. At a later stage of therapy, cognitive restructuring may be used to address underlying negative core beliefs. As a precursor to working with core beliefs, addressing cognitive distortions and rationalizations such as “Just a few more minutes won’t hurt” may help in managing primary symptoms. Although research evidence is limited (Su, Fang, Miller, & Wang, 2011), some studies have attempted to treat Internet addiction in an online setting. Although this may be compared somewhat unfairly to treating alcoholism in a pub, this approach presents some advantages. Principally, it allows clinicians to reach a subgroup of problem users who otherwise would not present in treatment. Clients with generalized anxiety and/or agoraphobic tendencies in addition to Internet addiction may have significant difficulty in even leaving the home to present at a treatment center. In summary, Internet addiction is an emerging disorder of growing relevance to adolescent clinical populations. Internet-related problems may be due in part to the increasing uptake and use of online-enabled devices among young people in home and school contexts. Although the literature in this area is still quite new, and there is no consensus as to assessment and therapy 1194 Journal of Clinical Psychology: In Session, November 2012 protocol, a small evidence base suggests that CBT has good preliminary support in treating addicted adolescents. Progress in established fields of adolescent addiction (e.g., pathological gambling) may be translated successfully to Internet addiction. Randomized, controlled trials using manualized CBT treatment protocols are needed to advance the field, in terms of both improving overall research quality and making more specific recommendations to clinicians. Selected References and Recommended Readings Beard, K. W. (2005). Internet addiction: A review of current assessment techniques and potential assessment questions. CyberPsychology & Behavior, 8, 7–14. 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