Psychotherapy in the Age of the Computer

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JOURNAL OF ADDICTIONS NURSINGVolume 13, Numbers 3/4, 2001Q Mary Ann Liebert, Inc.

Psychotherapy in the Age of the Computer:

The Debate Concerning Computer AddictionValerie A. Hart, EdD, RN, CS

Abstract

The emergence of th e World Wide Web andits explosive growth has affected every part ofthe human condition, and psychotherapy is noexception. Each day millions are visiting web-sites devoted to any topic imaginable. Particu-

larly popular are websites known for chatroomsand self-help groups. While these websites mayprovide support and opportunity for interaction,some people find themselves engaged in onlinebehavior to an excessive degree. While someclinicians are specializing in the treatment of

computer addiction and regard it as a disorderothers view the discussion as nothing more thana current fad. Is a potentially new psychiatricdiagnosis emerging, which is called by suchvarious names as Internet Addiction, Patholog-ical Internet Use, and Compulsive Internet Dis-order? This paper will explore the various com-ponents of the debate. Both potentially harmfulas well as positive aspects of computer use willbe discussed as well as criteria that can be use-fu l during the assessment of a client who pre-sents with concerns about computer use. Sev-eral self-reports will be included along with aclinical case example drawn from the author’sclinical practice. Treatment implications will beidentified and resources for further informationfor both clients and treating clinicians will be

discussed.

Introduction

Despite the fact that little research had beenconducted on the topic of Internet Addiction the

University of Southern Maine College of Nursing and Health Pro-

fessions, Portland, ME.

popular press has discussed it, a woman inFlorida lost custody of her children due to it ,

treatment facilities both online and off special-ize in it and a journal was recently launched,devoted to the topic of cyberspace and psy-chology. The term “Internet Addiction” was re-portedly first used as a post on an electronic

message board for professionals by Ivan Gold-berg as a joke (Garrison et al. 1995). Since thenthe debate about whether a real phenomenon ex-ists or not has been hotly debated, both onlineand in the journals.

The Argument For

The phenomenon of “Computer Addiction”was first studied in 1996 (Young 1996) usingquestions similar to those asked of potential al-

coholics or compulsive gamblers. In making adiagnosisof computer addiction Young uses thesame seven criteria which include: withdrawal;tolerance; preoccupation with the computer;more frequent use than intended; centralized ac-tivities to procure more of the activity; loss of

interest in other social, occupational and recre- ’

ational activities, and distress for the psycho-logical consequences caused by the use of thecomputer. In the literature similar diagnosticcriteria have been applied to a number of prob-

lem behaviors including sexual addictions(Goodman 1993), gambling (Griffiths 1990),eating disorders (Lesier and Blume 1993), andvideo game addiction (Griffiths 1991;Keepers1990).

To screen for Internet dependency the Cen-ter for Online Addiction was developed byYoung and uses an eight item screening ques-tionnaire adapted from the diagnostic criteriafor pathological gambling.

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Do you feel preoccupied with the Internet(think about previous online activity or an-ticipate next on line sessions)?Do you fee l the need to use the Interne t withincreasing amounts of time in order to

achieve satisfaction?Have you repeatedly made unsuccessful ef-forts to control, cut back, or stop Internet use?Do you feel restless, moody, depressed or ir-ritable when attempting to cut dow n or s topInternet use?Do you stay online longer than originally in-tended?Have you jeopardized or risked the loss of asignificant relationship, job, educational orcareer opportunity because of the Internet?Have you lied to family mem bers, therapists

or others to conceal the extent of involve-ment with the Internet?Do you use the Internet as a way of escap-ing from problems or of relieving a dys-phoric mood (e.g. feelings of helplessness,guilt, anxiety, depression)?Based on the results from on line self-reports

Young has estimated that between 6 and -10%of on line users experience difficulty with com-puter use. In further studies the connection hasbeen made between this same population andhigh rates of depression (Young and Rogers1998). The Beck Depression Inventory wasused with 259 subjects identified as havingpathological Internet behavior and the reportedfindings include mild to moderate depression.The correlation, however, is unclear and thereis no generally accepted definition of patholog-ical computer use. This study is also based onself-reports, another fact that critics cite as areason for caution when attempting to drawconclusions (Stein 1997).

Shapira and colleagues (2000) used face-to-

face standardized psychiatric evaluations toidentify behavioral characteristics and p sychi-atric com orbidity or family psychiatric historyin twenty individuals. In this small sample allsubjects had at least one Axis I diagnosis in ad-dition to their problems with the Internet and70% m et the criteria of B ipolar Disorder. Orig-inally the authors were testing out the hypoth-esis that there was a connection between prob-lem Internet use and Obsessive-Compulsive

Disorder. They speculated that those with Ob-sessive-Compulsive Disorder may be at ahigher risk. It has been suggested that the un-certainty of the “hit rate” in Internet searchingmay have a reinforcing and addictive effect sim-

ilar to playing the slot machines while othersspeculate that the Internet provides a safe envi-ronment fo r interaction and self-expression forthe shy and socially awkward (Griffiths 1997).Research conducted in the mid-1980’s foundthat “computer addicts” were introverted andeducated males who used computers in theirprofession (Shotton 1991). Later surveys havealso confirmed that the vast majority of Inter-net users are male (Pitkrow and Kehoe 1996).

Part of the intense draw for Internet usersmay be the fact that a participant can create a

persona and can literally invent their onlineidentity. The chat room is the stage on whichone can act out new roles where one can alterphysical characteristics, personality traits, andsocioeconomic status. A purely text-based ide n-tity can be c reated that can be dram atically dif-ferent from one’s real identity. The interactivequality of the Internet allows the user to exp e-rience how others will respond to the new per-sona. Unexpressed personality traits and feel-ings of power and recognition can be played-outand have a pow erful reinforcing effect. The In-ternet can provide an alte rnative reality to usersallowing them feelings of immersion andanonymity that may be psychologically re-warding and perhaps lead to an altered state ofconsciousness (Griffiths 1995).

Confidential social support and online rela-tionships offer illusion of companionship with-out the demands of a real relationship. Socialwithdrawal, marital discord , and dissatisfactioncan be the natural spin-offs of excessive com-puter use. Conducting a satisfying relationship,

whether sexual in nature or not, can interferewith real relationships and present difficu lties ofintegration regarding aspects of a persona thatconflict with one’s true identity. Early data sug-gest that new Internet users are at a higher riskof “addiction” (Young 1996) and consideringthat an estimated 20-40 million additional peo-ple plan to enter this new arena each year, clin-icians need to be informed about this at-risk pop-ulation.



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The Argument Against

The argument against the reality of a discretediagnostic entity, such as Internet Addiction,also has support. There are sites dedicated to

the humor of the concept of pathology such asThe World Headquarters of Netaholics Anony-mous (http://www.safari.net/-padnetanon).Some psychologists argue that rather than rep-resenting a new diagnostic entity, computer be-havior problems rest on preexisting personalitytraits (Dvorak 1997; Grohol 1998). Other crit-ics argue that the studies have major flaws be-cause they have been self-reported as well asfraught with sampling and demographic in-equities (Suler 1999). It can also be argued thatanything you do well requires vast time and en-

ergy commitment. A concert pianist who prac-tices 5 hourdday, the professional golfer whohits 500 golf balls a day are examples of thisphenomenon. Although the media have enthu-siastically taken up the term “Internet Addic-tion” and some professionals have created treat-ment centers devoted to the diagnosis there isalso the argument about the positive aspects ofuse of the Internet for mental health. Suler(1999) has described the various human needsthat can be met in cyberspace. These includesexual needs, a need for altered states of con-sciousness (particularly met in virtual or fan-tasy activity), need for mastery and achieve-ment, need to belong, need for relationships,and a need for self-actualization and transcen-dence of self. Ryder argues for the concept of“integration” as opposed to labeling extensiveactivity as addictive and asks, “Was Picasso ad-dicted to painting?’, or “Einstein addicted tophysics?’ Suler’s “integration principle’’ is:

Internet use becomes pathological when it is dissoci-

ated from in-person life. It becomes healthy when itis integrated with in-person living (2000).

King (1998) has identified the value of on-line self-help groups. Online communicationchanges the typical cues humans use in face-to-face encounters. A lack of information regard-ing status, position, age, race, and gender tendto level the playing field of communication.Communication is “reduced to its elemental

state of the exchange of ideas and concepts”which can create ease for the communicator.The range of social networks available to theInternet user can add a level of diversity for theuser (Wellman 1996). There is also control over

the type and amount of self-disclosure infor-mation that group members share. A sense of

community can form in self-help groups thatmay counter the impersonal nature of people’slives, and the Net can become a “surrogate so-

cial life” (North 1996). Social support, practi-cal information, shared experiences, positiverole models, helper therapy, empowerment,professional support, and advocacy efforts areall factors that operate online (Madara 2000).E-mail online support groups provide the addi-tional advantages of “24-hour availability, se-

lective participation in entering and respondingto messages, anonymity and privacy, immedi-ate and/or delayed responding, and recording oftransmissions.” (Sparks 1992). It is argued thatfor people in isolated or rural areas, or who areconfined to home due to disabilities that pre-vent travel, or who have emotional disabilitiesthat inhibit peer support, that on-line self-helpgroups are a valuable opportunity for connec-tion and support (Madera and White 1997). Onestudy of young single mothers who were givencomputers in order to connect with peers for thepurpose of peer support, parenting advice, andcoping skills showed a high level of use andoverall decrease in stress (Dunham 1997).

The Value of Case Studies

The debate over how legitimate the diagno-sis of Internet Addictions will no doubt con-tinue, as will the research efforts aimed at clar-ifying whether such a diagnostic category ought

to be included in the next edition of DSM. Allof the studies thus far have been self-reportedsurveys, which therefore have drawbacks. Fu-ture studies will no doubt address this issue. Butwhether “Computer Addiction” will ever findits way into DSM-V does not negate the factthat clients will present with their use of thecomputer causing major disruption in theirlives. Case studies of excessive Internet usersmay provide better evidence of whether Inter-



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net addiction exists because the data collectedis more detailed (Griffiths 1999). Young is inthe process of writing a book of just such casestudies which will detail the experience of thosewho have identified computer use as causing

damage to their lives (personal communication,2001). There is the 43-year-old homemakerwhose Internet use resulted in significant im-pairment to her family life as outlined by Young(1996). During a three-month period she spent50-60 hours a week online, primarily in chatrooms. Obviously, she began to experience dif-ficulties in many realms, including family life,marital relationship, as well as financial diffi-culty due to phone bills. Other examples includethe several teenage boys, the middle-agewoman with physical disabilities, and the male

in his early thirties all of whom Griffiths de-scribed (1997). Typical patterns include spend-ing excessive hours at the computer, often dur-ing the night and continuously during theweekend; and the descriptions by these usersthat the computer became the focal point in theirlives, to the detriment of other activities andpeople in their lives.

E.M., a 42-year-old married woman, pre-sented for psychotherapy to the author with thefollowing complaint about her computer use:

I never have time to do the things I used to enjoy, or

even time with my husband. I find myself leaving

work early just to log-o n. It is destroying my marriage

and threatening my career.

Internet addicts may operate on the same con-cept of “triggers” that plague other type of ad-dicts. Computer time may serve to provide emo-tional relief, mental escape, and a way to avoidinner conflicts, much as drugs, shopping, sex,or alcohol do. The type of application the user

is prone to gravitate toward ought to be as-sessed, along with the emotions and cognitionwhile online. Also, the clinician needs to askhow the client feels when offline as well as thenature of the client’s cognitions pertaining toself or self-esteem. E.M. became animatedwhen discussing her time spent in chat rooms.There she had adopted a flirtatious persona withan easy, sexy edge. She would describe to me

the reaction she would get when “entering theroom” from the men who were there ahead ofher. Even her name, “Holly,” suggested a care-free spirit. While there she would openly en-gage in breezy sexual repartee and found her-

self even following up with phone sex withsome of the men she met online. She becameafraid that she would take the next step and ac-tually meet one of them in person for a sexualencounter. She commented that the only thingthat prevented this behavior was her weight,which was a lifelong misery for her. This fan-tasy and temptation both excited and repulsedher and she clearly understood that her marriagecould be at risk if she were “found out.” E.M.worked for a large corporation as a technicalwriter. She had been married for 15 years, had

no children, and was visibly upset during herfirst session, openly crying and expressing herdistress and fear for her future.

Clearly this client had identified that thecomputer use was causing her distress, due to

the potential problems at work and within hermarital relationship. In my experience it is alsocommon to have the use only surface aftersome time in treatment, as it has the quality ofa “dirty secret” that the client may be in denialabout as well. Addictive behaviors of any typecan act as a lubricant to cope with unfulfilled

needs. The cues to identification and then treat-ment is to view the behavior as having mean-ing and to address the meaning, whether it beunderlying dissatisfaction in relationships orcareer, spiritual life, or concerning one’s senseof Self.

While E.M. and I explored her “real life,” asopposed to the life of “Holly,” we discoveredthat there was a clear impoverishment for herin her marriage. Her husband worked nights andhad a separate bedroom, although he was

thought of as a kind and loving man. She lackedclose woman friends and had chronic issues oflow self-image dating back to early childhood.We came to the conclusion that her online timeas “Holly” was much more exciting than herday-to-day existence and that the answer to re-ducing her time in chat rooms was to look atwhat was missing in her marriage and life andto examine how to make changes there.



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Treatment Considerations

Moderation and controlled use versus absti-nence should be the treatment goal for clients.Several techniques have been reported in the

literature. These include setting goals, ab stain-ing from a particular application (chat rooms),the use of external stoppers, reminder cards, de-velopment of a personal inventory, entering asupport group, and family therapy (Shotton1991; Young et al. 1999). Time-managementtechniques, however, will not correct patho-logical use because they do not address under-lying conflicts. Other treatment strategies suchas sex-offender therapy, social skills training,and pharmacological interventions have alsobeen utilized.

In my work with E.M. we worked on under-standing what was missing in her m arriage andin herself. This was a painful journey in whichshe traced feeling “invisible” in her family of

origin and the “ugly duckling that never turnedinto a swan.’’

Eventually, E.M. was able to identify thatmuch of her online sexual activity was not infact that sexually satisfying to her. W hat madeit powerful was her ability to please an onlinepartner. Online she was not invisible with hersexy and free-spirited persona. She got imme-diate reactions when entering a chat room andmany offers of further contact, usually of a sex-ual nature. T his app roval-seeking behavior be-came our new template for understanding thisbehavior.

The relationship with her husband, which shebegan to pay more and more attention to, andspend time with him, began to markedly im-prove. She had previously noted the irony of

her sleeping husband being in the next roomwhile she engaged in cybersex. Slowly, as she

and her husband began talking more and spend-ing time together, her time online decreasedwithout any limits or direction imposed by me,her therapist.

The Internet offers a wide menu. It is a bit likeNew York City, with the best of every thing imag-inable and also the worst. It can be a mighty re-source for clients and clinicians alike, or be thedark road down which clients net lost and escaDe

from life and all that life has to offer by way ofrelationships. This area of research is very new;future studies will determine who m ight be at riskfor running into difficulty and how best we mighttreat these individuals. For the clinician there is

an extensive list of online articles available athttp:/hww.netaddiction.com,which also has animpressive bibliography of articles about onlineresearch methods.

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