Psychosocial interventions for technological addictions

Abstract

Increase in the use of technology has led to an increase in various kinds of technological addictions. A range of psychological and behavioural theories has been proposed to explain technology addictions. These include learning theories, reward-deficiency hypothesis, impulsivity, cognitive-behavioural models and social skills deficiency theories. While no particular form of psychological intervention has been suggested as being the golden standard for its treatment, the most frequently investigated approaches have been cognitive behavioural therapy (CBT) and motivational enhancement therapy. Given the need for the use of technology in daily living, controlled use has taken precedence over complete abstinence as the goal of treatment for technology addictions. Therapeutic techniques suggested for internet addiction include practicing the opposite, using external stoppers, setting goals, selective abstinence from certain applications, using cues, making personal inventories, joining support groups and family therapy interventions.

INTRODUCTION

The present article provides an overview of interventions for technological addictions. Psychosocial interventions capitalize on psychological or social actions to produce change in psychological, social, biological as well as functional outcomes.¹ Psychosocial interventions for mental health and substance use disorders are interpersonal or informational activities, techniques or strategies that target biological, behavioural, cognitive, emotional, interpersonal, social, or environmental factors with the aim of improving health functioning and well-being.²

Outcomes of psychosocial interventions encompass desired changes in three areas: (1) symptoms, including both physical and mental health symptoms; (2) functioning, or the performance of activities, including but not limited to physical activity, activities of daily living, assigned tasks in school and work, maintaining intimate and peer relationships, raising a family, and involvement in community activities; and (3) well-being, including spirituality, life satisfaction, quality of life, and the promotion of recovery so that individuals “live a self-directed life and strive to reach their full potential”.³ Due to recent advancement of technologies, there is a need to conceptualize the interventions for technological addictions.

THEORETICAL BACKGROUND

As with most addictive behaviours, a range of psychological and behavioural theories has been proposed to explain technology addictions.

1. Learning theory emphasizes the positive reinforcing effects of technological use, which can induce feelings of well-being and euphoria in the user, and works on the principle of operant conditioning.⁴ The ‘reward-deficiency hypothesis' suggests that those who achieve less satisfaction from natural rewards (food, water, sex) turn to substances to seek enhanced stimulation from reward pathways. Technology use provides immediate reward with minimal delay, mimicking the stimulation provided by alcohol or drugs.⁵ Impulsivity is seen as a risk factor for the development of addiction. Internet use is linked to sensation-seeking behaviour, which is a sub-trait of impulsivity.⁶ Individuals who are impulsive tend to use internet as a sensation-seeking tool and may become addicted to it.

2. Cognitive- Behavioural model

Catastrophic thinking might contribute to compulsive internet use in providing a psychological escape mechanism to avoid real or perceived problems.⁷ Studies have revealed specific maladaptive cognitions such as over generalizing or catastrophizing and negative core beliefs that contribute to compulsive use of the Internet.⁸,⁹,¹⁰,¹¹

3. Social skills deficit theory

Individuals with poor social competence who may also be anxious about social interactions are drawn to the anonymity of the internet and the opportunities it affords for developing relationships in less threatening circumstances than those occurring face-to-face.¹²

Situational factors play a role in the development of technological addiction. Individuals who feel overwhelmed or who experience personal problems or who experience life-changing events such as a recent divorce, relocation, or a death can absorb themselves in a virtual world full of fantasy and intrigue.¹³

Examples of Psychosocial Interventions

There is no widely accepted categorization of psychosocial interventions. The term is generally applied to a broad range of types of interventions, which include psychotherapies (e.g. psychodynamic therapy, cognitive-behavioural therapy, interpersonal psychotherapy, problem solving therapy), community-based treatment (e.g. assertive community treatment, first episode psychosis interventions); vocational rehabilitation, peer support services, and integrated care interventions. Each theoretical orientation encompasses a variety of interventions (e.g. within psychodynamic orientations are relational versus ego psychological approaches; within behavioural orientations are cognitive and contingency management approaches). See the following Box for the examples.

Box 1.

General overview of psychosocial interventions

Efficacy of Psychosocial Interventions

The efficacy of a broad range of psychosocial interventions has been established through several randomized controlled clinical trials and numerous meta-analyses.¹⁴,¹⁵,¹⁶,¹⁷,¹⁸,¹⁹,²⁰ Psychosocial interventions often are valuable on their own but also can be combined with other interventions, such as medication, for a range of disorders or problems. In addition, interventions can address psychosocial problems that negatively impact adherence to medical treatments or can deal with the interpersonal and social challenges present during recovery from a mental health or substance use problem. Sometimes multiple psychosocial interventions are employed.

Psychotherapy

When it comes to psychotherapeutic interventions for technological addictions, no particular form of psychological intervention can be suggested as being the golden standard for its treatment. However, the most frequently investigated approaches have been cognitive behavioural therapy (CBT) and motivational enhancement therapy.²¹,²²

The psychotherapeutic intervention can also be done under two contexts – Total abstinence and Controlled Use. Given the internet's numerous advantages and positive uses in day-to-day life, it is impractical to try the total abstinence model (as in treatment of substance use disorders), even in those who are person suffering from an addiction to the internet. The guiding principle should primarily be ‘moderate and controlled use’. In the abstinence model, the individual abstains from a particular internet application (e.g. using chat rooms or playing games) and uses other applications in moderation. This model of abstinence is recommended for those who have tried and failed to limit their use of a particular application.²³

Those who have asserted that internet (technological) addiction is primarily maintained cognitively believe that cognitive behavioural therapy may be a possible solution.¹⁰ This addiction is formed once the patients feel they have no social and family support, thereby developing the so-called maladaptive cognitions (which are the mental evaluations or screeners of interpretation) about themselves and the world. Therapeutic strategies would include cognitive restructuring regarding the Internet applications an individual uses most often, behavioural exercises, and exposure therapy, in which the individual stays offline for increasing amounts of time.

Young suggests eight therapeutic techniques for internet addiction.²² These include:

1. Practice the opposite: Discover clients' patterns of internet use and disrupt these patterns by suggesting new schedules. For example, if the patient goes online as soon as he or she arrives home from work and remains online until it is time to go to bed, the clinician may suggest that he or she take a break for dinner, watch the news, and only then go back to the computer.

2. External stoppers: Clients can use real events or activities to prompt themselves to log off of the internet. For example, the use of an alarm clock to function as a warning for the patient that it is time to turn off the computer and carry out some other offline activity, such as going to work or school.

3. Setting goals: Help clients to come up with specific, achievable goals with regard to the amount of time spent online. For example, if the patient remains online all day long on Saturdays and Sundays, a schedule with brief sessions of use followed by brief, although frequent, discontinuations could be designed.

4. Abstinence from certain applications: Encourage abstinence to only those applications that the client is unable to control. This means that patients should stop navigating particular web sites or even certain applications (e.g. MSN, Facebook, online games) that are most attractive for them, discontinuing the use from time to time, shifting to alternative forms such as sending and receiving e-mails, news search, bibliographical sources for their school work, and so forth.

5. Reminder cards: Use visible cues that remind the clients of the costs of their internet addiction and the benefits of breaking the addiction. For example, a card containing the five major problems caused by internet addiction, as well as the five major benefits from reducing the use (or ultimately refraining from using a given application) should be listed.

6. Personal inventory: Help the clients to recognize the benefits of breaking their habit by showing them all the activities that they used to engage in or cannot find the time for because of internet addiction.

7. Support groups: These are useful because many Internet addicts are said to use the Internet to compensate for a lack of social support.

8. Family therapy: Family interventions are necessary to address relational problems that may have contributed to or resulted from internet addictions. Some people with internet addiction who develop financial problems may benefit from financial counseling. Marriage (or couples) counselling may be helpful when internet addiction in one member of the dyad has disrupted the relationship. Young especially recommended couples therapy for cyber-sexual addiction.²⁴ Likewise, family therapy may be helpful when problematic behaviours have disrupted the family unit. Caldwell and Cunningham suggest that a combination of behaviour modification, emotionally focused intervention, cognitive restructuring and crisis management could be considered, depending on the presenting problem.²⁵

Motivational Enhancement Therapy is a technique in which there is a collaborative, non-confrontational effort by the person with internet addiction and the therapist to create an individualized treatment plan and attainable goals.²⁶ Motivational interviewing helps the client to understand how he or she feels just before going online and then pinpointing the types of emotions being covered by the behaviour (how these feelings diminish when online, looking for how the client rationalizes or justifies using the Internet (e.g. “Chatting makes me forget about the fight with my husband”). Motivational interviewing is also meant to help the client recognize consequences stemming from excessive or compulsive use. Problems may consist of issues like “My spouse becomes angry.” The therapeutic relationship is more like a partnership or companionship than an expert/recipient relationship to examine and resolve ambivalence. The operational assumption in motivational interviewing is that ambivalence is the principal obstacle to be overcome in triggering change.

TREATMENT CENTRES

The Centre for Internet Addiction Recovery (http://www.netaddiction.com) is a Web-based treatment facility designed specifically for help with Internet addiction that provides e-counseling, self-help books and tapes and online support groups. The logic of conducting counselling and treatment via the medium that is problematic has been questioned²⁷ and empirical support for these treatments is sparse.

Offline treatment centres for Internet Addiction with inpatient facility have been established across the US, and half-way houses for adolescents with internet addictions have been opened in China. India opened its first clinic (SHUT clinic-Service for Healthy use of Technology) in 2014, at NIMHANS centre for well-being in Bengaluru, Karnataka. Outcome data for these centres have not been rigorously evaluated.

Treatment Programmes in China and Korea

Today, countries like South Korea and China consider technology addiction as a public health crisis. To date, most of the literature concerning internet addiction in Asian countries like China, Korea are case reports. To address this problem, the Korean government has built a network of 190 Internet addiction counselling centers and hospitals, and has trained 1,043 counselors in the treatment of Internet addiction, as of 2007.²⁸ The country's first specialist clinic for this problem has opened in May, 2011 and they offer a five week treatment module which includes group sessions, art therapy, medicines, neuro-feedback and transcranial magnetic stimulation.²⁹ China has over 300 treatment centres. In China, the General Hospital of Beijing's Military Region's Addiction Medicine Centre have included both behavioural training and pharmacotherapy for the client like – dancing and sports, reading, karaoke and elements from the 12 step programmes of the Alcoholic Anonymous, along with family therapy.³⁰

CLINICAL APPLICATION

A 14 year- old adolescent boy with borderline Intelligence (IQ + 78, assessed using Binet Kamat test) presented with excessive online gaming, anger outbursts, using abusive language towards the parents and deterioration of academic performance. Presence of increased stubbornness and demanding behaviour for the last two years. He was playing games on an average 10-12 hours a day. Due to this, academic performance also decreased.

At the age of 11 years, he started using his parents' mobile phone. He was a single child. Parents' academic expectations were high. He was unable to cope up with the studies. He started using the desktop, started spending more time on online activities, whenever he used to be at home. For the past two years, he was irregular to school and online gaming increased. Most of his games involved shooting. He would also search for gaming devices through online shopping. He stopped going to school regularly and had shifted many schools. Personal hygiene, sleep and appetite got disturbed, and his hobbies such as Kung Fu classes stopped.

The parents forcefully stopped his gaming. However, he would keep thinking about it most of the time, including when he was not playing. Sometimes he would bang his head to wall when they tried to stop him. Parents were overinvolved and extremely worried about his gaming behaviour.

The child also developed self-harm behaviours since one year. Sometimes when his demands were not met, he would get angry and bang his head on the wall. One month prior to the consultation, he made a suicidal attempt by jumping from the third floor. He would spend the entire the time in online gaming, and there was subsequent impairment in his biological functions with significant mood fluctuations. His mother was diagnosed as having obsessive compulsive disorder, which also resulted in her increased expectations of him doing activities perfectly.

Internet Addiction Test was applied, on which he scored 56, which indicated problematic internet use. Problematic Online Gaming Questionnaire was also administered, wherein he scored high in all the test domains like Preoccupation, Immersion, Withdrawal, Overuse, Interpersonal Conflicts and Social Isolation.

Motivational Interviewing was used for reducing gaming and internet use behaviour. Behaviour activation was done and a contingency contract was made for restricted usage. Online time management was set with alarm clocks. He was asked to maintain a diary for his usage pattern and relaxation techniques were taught. Family psychoeducation and attempts to reduce the expressed emotions were made. Reinforcement strategies with the boy were explained to the family.

SUMMARY AND FUTURE DIRECTION

We live in an era where there is a consistent engagement with technology, culminating into gradual dependence on it. There are times when it is necessary to use technology in ways that are meaningful and productive, but this often blurs the line between necessity and addiction. The family is the core group based on which patterns of action are developed and constructive methods of conflict resolution can also be determined. Compassion, empathy, solidarity, and personal responsibility can be learned in the family. These attributes can serve as models and resources for the client to make changes within the extended environment. Integrating the system into treatment of technological addiction therefore seems a reasonable and useful approach. As with other addiction therapies, perseverance and loving firmness on the part of therapist and family members are required to bring about changes. Commitment can pay off because therapeutic assistance can favour and enable constructive long-term development, especially in young people. More research is needed in the future to assess the effectiveness of different treatment methods. What is now certain is that young people need committed individuals in their everyday lives, whether in the family, at school, or in their circle of friends and acquaintances. In the interest of prevention, the ultimate objective is to create an environment that offers appealing opportunities for challenges, encounters and participation so that young people can be shaped by the incomparable uniqueness of genuinely experiencing real life with all of their senses.