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Cured meets: Treating addictive behaviours

Addiction is a highly prevalent problem within today’s society and there is a lot of time and many spent in trying to prevent and treat the behaviour. There has also been a move towards getting addicts motivated to want to change their behaviour. The most influential model worldwide is probably the ‘stages of change’ model by Dr. James Prochaska and Dr, Carlo Di Clemente that identifies an individual’s ‘readiness for change’ and tries to get a person to a position where they are highly motivated to change their behaviour. The individual stages of this model are:

  • Precontemplation – This is where the person unaware of the consequences of his or her own behaviour and no change in behaviour is foreseeable.
  • Contemplation – This is where the person aware problem exists and is contemplating change.
  • Preparation – This is where the person has decided to change in the near future (e.g., New Year resolution).
  • Action – This is where the person effects change (e.g., gets rid of all association items related to the behaviour).
  • Maintenance – This is where the person consolidates behaviour change over time.
  • Relapse – This where the person reverts to a former behaviour pattern (e.g., contemplation, preparation).

People can stay in one stage for a long time and it is also possible for unassisted change such “maturing out” or “spontaneous remission”. Various techniques can be used to help people prepare for readiness include motivational techniques, behavioural self-training, skills training, stress management training, anger management training, relaxation training, aerobic exercise, relapse prevention, and lifestyle modification. The goal of treatment can be either abstinence or simply to cut down.

The intervention and treatment options for the treatment of addiction include, but are not limited to counselling/psychotherapies, behavioural therapies, cognitive-behavioural therapies, self-help therapies, pharmacotherapies, residential therapies, minimal interventions and combinations of these (i.e., multi-modal treatment packages). The most important of these are outlined below.

Pharmacotherapy: Pharmacological interventions basically consist of addicts being given a drug to help overcome their addiction. These are mainly given to those people with chemical addictions (e.g., nicotine, alcohol, heroin, etc.) but are increasingly being used for those with behavioural addictions (e.g., gambling, sex, work, exercise, etc.). For instance, some drugs produce an unpleasant reaction when used in combination with the drug of dependence, replacing the positive effects of the drug of dependence with a negative reaction. For instance, alcoholics are sometimes prescribed disulfiram (more commonly known as Antabuse), that when combined with alcohol may produce nausea and vomiting. Other common therapies include methadone and the use of opioid antagonists (such as nalaxone or naltrexene) for heroin addiction. The methadone prevents withdrawal symptoms, block the effects of heroin use, and decreases craving. The main criticism of all these treatments is that although the symptoms may be being treated, the underlying reasons for the addictions may be being ignored. On a more pragmatic level, what happens when the drug is taken away? Often, the addicts return to their addiction if this is the only method of treatment used.

Behavioural therapy: Behavioural therapies are based on the view that addiction is a learned maladaptive behaviour and can therefore be ‘unlearned’. These have mainly been based on the classical conditioning paradigm and include aversion therapy, in vivo desensitisation, imaginal desensitisation, systematic desensitisation, relaxation therapy, covert sensitisation, and satiation therapy. All of these therapies focus on cue exposure, and relapse triggers (like the sight and smell of alcohol/drugs, walking through a neighbourhood where casinos are abundant, pay day, arguments, pressure, etc.). The theory is that through repeated exposure to ‘relapse triggers’ in the absence of the addiction, the addict learns to stay addiction free in high-risk situations. It could be argued that if the addiction is caused by some underlying psychological problem, (rather than a learned maladaptive behaviour), then behavioural therapy would at best only eliminate the behaviour but not the problem. This therefore means that the addictive behaviour may well have been curtailed but the problem is still there so the person will perhaps engage in a different addictive behaviour instead.

Cognitive-behavioural therapy: A more recent development in the treatment of addictive behaviours is the use of cognitive-behavioural therapies (CBT). There are many different CBT approaches that have been used in the treatment of addictive behaviours including rational emotive therapy, motivational interviewing, and relapse prevention. The techniques assume that addiction is a means of coping with difficult situations, dysphoric mood, and peer pressure. Treatment aims to help addicts recognise high-risk situations and either avoid or cope with them without use of the addictive behaviour. In relapse prevention, the therapist helps to identify situations that present a risk for relapse (both intrapersonal and interpersonal). Relapse prevention provides the addict with techniques to learn how to cope with temptation (positive self statements, decision review, and distraction activities), coupled with the use of covert modelling (i.e., practicing coping skills in one’s imagination). It also provides skills for coping with lapses (by redefining what is happening), and utilizes graded practice (a desensitization technique where addicts encounter real life situations slowly). Overall, CBT approaches are better researched than the other psychological methods in addiction but are probably no more effective (Luty, 2003).

Psychotherapy: Psychotherapy can include everything from Freudian psychoanalysis and transactional analysis, to more recent innovations like drama therapy, family therapy and minimalist intervention strategies. The therapy can take place as an individual, as a couple, as a family, as a group and is basically viewed as a ‘talking cure’ consisting of regular sessions with a psychotherapist over a period of time. Most psychotherapies view maladaptive behaviour as the symptom of other underlying problems. Psychotherapy often is very eclectic by trying to meet the needs of the individual and helping the addict develop coping strategies. If the problem is resolved, the addiction should disappear. In some ways, this is the therapeutic opposite of pharmacotherapy and behavioural therapy (which treats the symptoms rather than the underlying cause). There has been little evaluation of its effectiveness although most addicts go through at least some form of counselling during the treatment process.

Self-help therapy: The most popular self-help therapy worldwide is the Minnesota Model 12-Step Programme (e.g., Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Sexaholics Anonymous, etc.). This treatment programme uses a group therapy technique and uses only ex-addicts as helpers. Addicts attending 12-Step groups involves them accepting personal responsibility and views the behaviour as an addiction that cannot be cured but merely arrested. To some it becomes a way of life both spiritually and socially and compared with almost all other treatments it is especially cost-effective (even if other treatments have greater success rates) as the organization makes no financial demands on members or the community. For the therapy to work, the 12-Step Programme asserts that the addict must come to them voluntarily and must really want to stop engaging in their addictive behaviour. Further to this, they are only allowed to join once they have reached “rock bottom”. To date there has been little systematic study of 12-Step groups but drop out rates are very high (typically 80-90%). There are a number of problems preventing evaluation, particularly anonymity, sample bias, and what the criterion for success is. The empirical evidence suggests that self-help support groups’ complement formal treatment options and can support standardized psychosocial interventions.

When examining all the literature on the treatment of addiction, there are a number of key conclusions that can be drawn. These include that: (i) treatment must be readily available, (ii) no single treatment is appropriate for all individuals., (iii) it is better for an addict to be treated than not to be treated, (iv) it does not seem to matter which treatment an addict engages in as no single treatment has been shown to be demonstrably better than any other, (v) a variety of treatments simultaneously appear to be beneficial to the addict, (vi) individual needs of the addict have to be met (i.e., the treatment should be fitted to the addict including being gender-specific and culture-specific), (vi) clients with co-existing addiction disorders should receive services that are integrated, (vii) remaining in treatment for an adequate period of time is critical for treatment effectiveness, (viii) medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies, (ix) recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment, (x) there is a direct association between the length of time spent in treatment and positive outcomes, and (xi) the duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1996). Pathological gambling and its treatment. British Journal of Clinical Psychology, 35, 477-479.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Griffiths, M.D. & H.F. MacDonald (1999). Counselling in the treatment of pathological gambling: An overview. British Journal of Guidance and Counselling, 27, 179-190.

Hayer, T. & Griffiths, M.D. (2015). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition) (pp. 539-558). New York: Kluwer.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

Luty, J. (2003). What works in drug addiction? Advances in Psychiatric Treatment, 9, 280–288.

National Institute on Drug Abuse (1999). Principles of drug addiction treatment: A research-based guide. NIDA.

Potenza, M. & Griffiths, M.D. (2004). Prevention efforts and the role of the clinician. In J.E. Grant & M. N. Potenza (Eds.), Pathological Gambling: A Clinical Guide To Treatment (pp. 145-157). Washington DC: American Psychiatric Publishing Inc.

Prochaska, J.O. and DiClemente, C.C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Melbourne, Florida: Krieger Publishing Company

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

United Nations Office on Drugs and Crime/World Health Organization (2008). Principles of Drug Dependence Treatment: Discussion paper. UN/WHO.

Assassin’s greed: An unorthodox way to treat gaming addiction

A couple of days ago, I was interviewed by BBC Online News for a story about a Chinese father (Mr. Feng) who hired ‘virtual assassins’ to hunt down his son in online video games and kill off his avatar as a way of trying to get his video game addicted son to stop playing online games. The story emanated from the Kotaku gaming website that reported:

“Feng’s 23 year-old son, ‘Xiao Feng’ started playing video games in high school. Through his years of playing various online games, he supposedly thought himself a master of Chinese online role playing games. According to his father, Xiao Feng had good grades in school, so they allowed him to play games; but when he couldn’t land a job they started looking into things. He, however, says he simply couldn’t find any work that he liked…Unhappy with his son not finding a job, Feng decided to hire players in his son’s favorite online games to hunt down Xiao Feng…Feng’s idea was that his son would get bored of playing games if he was killed every time he logged on, and that he would start putting more effort into getting a job…One thing’s for sure; Feng’s way of deterring his son from playing games might be one of the best ideas to come out of China recently, particularly as reactions to ‘gaming and internet addiction’ have been very extreme”.

My quotes from the story were reproduced in over 100 newspapers and website stories within a 48-hour period including the Daily Mail (UK), New York Daily News (US), Epoch Times (China), Times of India (India), Deccan Herald (India), Pakistan Today (Pakistan),  National Post (Canada), Kenya Daily Eye (Africa) and Expressen (Sweden). I was quoted as saying:

“It’s not going to do much for family relations. I‘ve never heard of that kind of intervention before, but I don’t think these top-down approaches work. Most excessive game playing is usually a symptom of an underlying problem. I’ve spent 25 years studying excessive video game playing. I’ve come across very excessive players – playing for 10 to 14 hours a day – but for a lot of these people it causes no detrimental problems if they are not employed, aren’t in relationships and don’t have children. It’s not the time you spend doing something, it’s the impact it has on your life.”

My quotes (somewhat paraphrased from a 15-minute interview) were based on my research examining the role of context in determining whether someone is addicted to online gaming (and which I discussed at length last year in a previous blog). To me, the core of the issue concerning video game addiction is the extent to which excessive gaming impacts detrimentally on someone’s life. If there are no negative consequences as a result of excessive gaming, I wouldn’t class it as an addiction. However, for me, the most interesting part of the story was the intervention by the man’s father in trying to wean his son off playing video games. I’m not convinced that the father’s approach would work in general (and I’m not convinced it worked in this individual case).

The issue of online gaming addiction is a hot issue in South East Asia, and the prevalence of problematic online gaming appears to be higher in countries such as China, South Korea, Taiwan, and Singapore, than in Europe and North America. In South East Asia, there is a growing concern in relation to the need to develop treatment programs for online computer game addiction. According to one report by the Korean government, 2.4% of its population was said to be addicted to video games. The report also indicated that mental health counselling bears a heavy stigma in Korea. In one case discussed in the report, the father of a child addicted to gaming refused to acknowledge his son had a problem for three months, even though he had borrowed substantial amounts of money from family members to support his addiction. Similar accounts have also appeared in China. Reports such as these indicate cultural concerns and differences.

China introduced an anti-online gaming system and a few clinics as a response to the growing problem of excessive playing of online games there. The system allows for three hours a day of gaming without penalties, but after three hours the values of items won in the game starts to decrease. After five hours of gaming per day no experience or benefits can be accrued. This system was clearly designed by those who know ‘how to hit players where it hurts’ so to speak. However, without further details of how the program operates, it is hard to evaluate whether this would work effectively given that people might be able to create multiple accounts (with characters in each account) to get round the blocking. Such a system will also require monitoring and evaluation, and would be much less effective in countries where the government allows a greater level of personal freedom.

Press reports indicate that China’s system to curtail excessive game playing only applies to adult gamers. However the Chinese solution was predictably unpopular with gamers and led to a mass exodus from one server to another server when first implemented. The Chinese system also includes: (i) the banning teenagers from cyber-cafes, (ii) limiting online gaming sessions, (iii) boot camps, (iv) psychological counselling, and (v) electrocution. There is little detailed information about the treatment technique utilized in these therapy centres. The ‘electrocution’ technique is apparently more akin to acupuncture, but it is still hard to see how that might help. It could be that it is a type of aversive therapy where they shock players whilst they are playing computer games – but this is entirely speculative on my part.

Finally, I am a great believer that the gaming addiction treatment should be fitted to the individual although some of my recent papers with my Australian colleagues Dr. Daniel King and Dr. Paul Delfabbro (at the University of Adelaide) have recommended cognitive-behavioural therapy (which I will look at in a future blog). The cognitive-behavioural model is both better researched (though with reference to different disorders), has tried and tested therapeutic techniques, and is underpinned by a verified psychological theory. However, further research is required to establish the therapeutic efficacy of all treatment programs directed at excessive gaming.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Beranuy, M., Carbonell, X., & Griffiths, M.D. (2013). A qualitative analysis of online gaming addicts in treatment. International Journal of Mental Health and Addiction, DOI 10.1007/s11469-012-9405-2

Griffiths, M.D. (1997). Video games and clinical practice: Issues, uses and treatments. British Journal of Clinical Psychology, 36, 639-641.

Griffiths, M.D. (2008). Diagnosis and management of video game addiction. New Directions in Addiction Treatment and Prevention, 12, 27-41.

Griffiths, M.D. (2010). Online video gaming: What should educational psychologists know? Educational Psychology in Practice, 26(1), 35-40.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Griffiths, M.D. & Meredith, A. (2009). Videogame addiction and treatment. Journal of Contemporary Psychotherapy, 39(4), 47-53.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology: In Session, 68, 1185-1195.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction: A systematic review. International Journal of Mental Health and Addiction, 10, 278-296.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.