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Ride on high: Another look at the psychology (and cycleology) of ‘cycling addiction’

Back in 2012, I wrote an article on cycling addiction for my blog and classed the behaviour as a sub-type of exercise addiction. Recently (June 2016), I was interviewed by Cycling Weekly magazine for an article on addiction to cycling, so I thought it opportune to look at the issue again. Over the last five years or so there has been an increase in the amount of research into exercise addiction (as I have outlined in a number of papers with my Hungarian colleagues Attila Szabo and Zsolt Demetrovics – see ‘Further reading’ below). However, there has still been no empirical research specifically into cycling addiction. In his 1997 book Motivation and Emotion in Sport, Dr. John Kerr speculated that endurance type exercise activities (e.g. running, cycling, swimming, aerobics and weight training) were most often associated with exercise addiction and dependence but this was based more on anecdotal as opposed to scientific evidence.

For the Cycling Weekly article, I was interviewed by Dr. Josephine Perry (who just happed to be both a psychologist and a cyclist). She noted in her article that:

“As a regular cyclist, it’s very likely you take a close interest in performance and have a strong drive to improve coupled with a willingness to push yourself hard in training and racing. Sometimes you probably feel under attack from family or colleagues who question or tease you about your ‘obsessive’ cycling habit. You no doubt retaliate by citing the many benefits of cycling: the brilliant friendships, massive health improvements, toned body and all the places you get to explore on your bike. But do your critics occasionally have a point? Does your relentless drive to improve sometimes go too far and place you in danger of crossing the thin line from dedication into addiction? Addiction to cycling is defined by an incessant internal need to train hard every day without taking the time off that you need to rest and recover — not to mention attend to other commitments in your life. In other words, addiction is defined by harm. You ignore the pleas from family or friends to cut back. Your priorities get rearranged, and nothing is allowed to come between you and your bike. Once this line is crossed, the benefits of cycling begin to diminish. The addicted cyclist feels more aches and pains, becomes prone to physical injuries, regular colds and hidden illnesses”.

In a recent (2016) book chapter, my colleagues and I noted that exercise addiction (irrespective of the sub-type) is a condition in which a regularly exercising person loses control over her or his exercise behaviour, while acting compulsively and exhibiting dependence, resulting in negative consequences in their day-to-day health and/or life. This maladaptive exercise behaviour is characterized by severe withdrawal symptoms when exercise is not possible, similar to both chemical addictions (e.g., alcohol addiction) and other behavioural addictions (e.g., gambling addiction). Based on the scientific evidence, exercise addiction is relatively rare, ranging from 0.3% to 0.5% as noted in the only study published using a representative national sample of the general population that we carried out in Hungary back in 2012 (published in the journal Psychology of Sport and Exercise). Given that exercise addiction (in general) is rare, the prevalence of cycling addiction would therefore be even lower. However, that doesn’t mean it doesn’t exist.

A recent study carried out by Dr. Bernd Zeulner and his colleagues among 1,031 endurance athletes (that included an unspecified number of cyclists) assessed the prevalence of exercise addiction using the Exercise Addiction Inventory (EAI; a scale that I co-developed with my colleagues Attila Szabo and Annabel Terry). The study (published in the journal Advances in Physical Education) found that 2.7% had the potential to develop an exercise addiction and that is higher than the prevalence among the general population.

Another study published in the Journal of Clinical Sport Psychology by Dr. Jason Youngman and Dr. Duncan Simpson examined exercise addiction among 1,285 triathletes (cycling, swimming and running) also using the EAI. The study found that approximately 20% of triathletes were at risk for exercise addiction, and that training for longer distance races puts triathletes at greater risk for exercise addiction than training for shorter races. They also found that as the number of weekly training hours increased, so did a triathlete’s risk for exercise addiction. Despite the lack of empirical evidence specifically on cycling addiction, Dr. Perry also noted in her article that:

“[Addicted cyclists] can also become susceptible to burnout and all that comes with it: decreased performance, low mood, changes in appetite, difficulty sleeping and generally a feeling that the outcomes are not matching the intensity of the effort being put in. For a cycling addict, this loss of form and the feelings of difficulty can be devastating…Other research has found the risks are highest in those exercising over five times a week. With the average amount of training for serious amateur cyclists being around 10 hours a week, they are certainly in the higher-risk category”.

I am not sure which study Dr. Perry is referring to in this quote, but in my interview with her, I noted that from my perspective, any behaviour can be potentially addictive if the reward mechanisms are in place but that we should be cautious about imposing the ‘addiction’ label. I told her that we can’t define whether someone is addicted just by the behaviour that they display. It is all to do with the context of that behaviour in their life. More importantly, it’s is not about the amount of time spent engaging in the behaviour but what impact the behaviour has on them. As I explained:

“A healthy enthusiasm adds to their life. An addiction takes away from it. If you have no dependants and both you and your partner enjoy the sport and there is no conflict, it would not be classed as an addiction. If family conflict becomes a factor, the exercise habit becomes fraught with complications.”

I noted in my previous blog on cycling addiction that one of the traits that appears to be associated with exercise addiction is perfectionism according to a 1990 paper by Dr. Caroline Davis that appeared in the journal Personality and Individual Differences. Research (by Dr. Heather Hasenblaus among others) has also found that extraversion, neuroticism, and agreeableness predict exercise addiction symptoms. I also noted in my interview with Dr. Perry that some people (such as those with Type A personalities) appear to have their risk for exercise addiction built into them. Some cyclists will be those Type-A achievers who are reward-orientated to do the best they can, in whatever they do. If they take up a sport, those personality traits previously used to be successful and focused in other areas such as work go into the new area.

I also noted in my Cycling Weekly interview that there are a number of signs that can help you spot if your attitude towards cycling is unhealthy. The most obvious one is when cycling becomes the most important activity in your life, dominating thinking, feelings and behaviour. If you need to cycle more to get the same mood benefit that you used to, your mood changes significantly and/or you feel physical effects when you can’t cycle, you may also be at risk. If you start to resent your family, job, social life, hobbies or other interests getting in the way of you cycling, you need to consider if you have crossed the line. Those addicted to cycling are more likely to get into debt to fund their habit, become excessively controlling over their eating to regulate weight and competitiveness, and find it hard to balance work, social and family commitments with training.

I was also asked for my views on the treatment of cycling addiction and said that cognitive-behavioural therapy would likely be the most effective (as the addict would be guided to identify goals that motivate them and be helped to find safe and reasonable ways to reach those goals) but that the type of treatment depends on whether the addiction to cycling was primary or secondary. Primary addicts, who are actually addicted because they love their sport, will find it is very hard to give up. Telling them they can’t continue will be stressful in itself. Secondary addicts may be trying to lose weight or to escape negative, unpleasant feelings or difficulties in their lives, using cycling to control their thoughts. These cyclists are using exercise as a coping mechanism. The key here is finding out why they are doing it to such an extent in the first place. Most will find their addiction is symptomatic of something else.

After interviewing me about whether cycling can be potentially addictive, Dr. Perry summed up my own views arguably better than I could have done it myself:

“[Cycling addiction] is not just about how many hours you are doing on the bike, how much you love your riding, or how many bikes you have; what matters is the impact on your life. If your work and family life allows it without conflict, and you’re not feeling over-stressed or over-tired, then your commitment to cycling is just that – a commitment. If you are suffering from continual injuries and not recovering fully, have found yourself feeling burnt out, dips in mood, feel obliged to miss family or social events for training, resulting in arguments, then you need to ask yourself seriously: am I addicted?”

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Allegre, B., Souville, M., Therme, P. & Griffiths, M.D. (2006). Definitions and measures of exercise dependence, Addiction Research and Theory, 14, 631-646.

Berczik, K., Griffiths, M.D., Szabó, A., Kurimay, T., Kökönyei, G., Urbán, R. and Demetrovics, Z. (2014). Exercise addiction – the emergence of a new disorder. Australasian Epidemiologist, 21(2), 36-40.

Berczik, K., Griffiths, M.D., Szabó, A., Kurimay, T., Urban, R. & Demetrovics, Z. (2014). Exercise addiction. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.317-342). New York: Elsevier.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2011). Exercise addiction: Symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, 47, 403-417.

Davis, C. (1990). Weight and diet preoccupation and addictiveness: The role of exercise. Personality and Individual Differences, 11, 823-827.

Freimuth, M., Moniz, S., & Kim, S.R. (2011). Clarifying exercise addiction: differential diagnosis, co-occurring disorders, and phases of addiction. International Journal of Environmental Research and Public Health, 8(10), 4069-4081.

Griffiths, M. D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The exercise addiction inventory: a quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39(6), e30-31.

Griffiths, M.D., Urbán, R., Demetrovics, Z., Lichtenstein, M.B., de la Vega, R., Kun, B., Ruiz-Barquín, R., Youngman, J. & Szabo, A. (2015). A cross-cultural re-evaluation of the Exercise Addiction Inventory (EAI) in five countries. Sports Medicine Open, 1:5.

Hausenblas, H.A., & Giacobbi, P.R. (2004). Relationship between exercise dependence symptoms and personality. Personality and Individual differences, 36(6), 1265-1273.

Kerr, J. H. (1997) Motivation and Emotion in Sport: Reversal Theory. Hove: Psychology Press.

Kerr, J.H., Lindner, K.J. & Blaydon, M. (2007). Exercise Dependence. Oxford: Rutledge.

Kurimay, T., Griffiths, M.D., Berczik, K., & Demetrovics, Z. (2013). Exercise addiction: The dark side of sports and exercise. In Baron, D., Reardon, C. & Baron, S.H., Contemporary Issues in Sports Psychiatry: A Global Perspective (pp.33-43). Chichester: Wiley.

Mónok, K., Berczik, K., Urbán, R., Szabó, A., Griffiths, M.D., Farkas, J., Magi, A., Eisinger, A., Kurimay, T., Kökönyei, G., Kun, B., Paksi, B. & Demetrovics, Z. (2012). Psychometric properties and concurrent validity of two exercise addiction measures: A population wide study in Hungary. Psychology of Sport and Exercise, 13, 739-746.

Perry, J. (2016). Are you addicted to cycling? Cycling Weekly, July 21. Located at: http://www.cyclingweekly.co.uk/fitness/training/are-you-addicted-to-cycling-261852

Szabo, A., Griffiths, M.D., de La Vega Marcos, R., Mervo, B. & Demetrovics, Z. (2015). Methodological and conceptual limitations in exercise addiction research. Yale Journal of Biology and Medicine, 86, 303-308.

Szabo, A., Griffiths, M.D. & Demetrovics, Z. (2016). Exercise addiction. In V. Preedy (Ed.), The Neuropathology Of Drug Addictions And Substance Misuse (Vol. 3) (pp. 984-992). London: Academic Press.

Terry, A., Szabo, A., & Griffiths, M. D. (2004). The exercise addiction inventory: A new brief screening tool. Addiction Research and Theory, 12, 489-499.

Youngman, J., & Simpson, D. (2014). Risk for exercise addiction: A comparison of triathletes training for sprint-, Olympic-, half-Ironman-, and Ironman-distance triathlons. Journal of Clinical Sport Psychology, 8, 19-37.

Zeulner, B., Ziemainz, H., Beyer, C., Hammon, M., & Janka, R. (2016). Disordered Eating and Exercise Dependence in Endurance Athletes. Advances in Physical Education, 6(2), 76.

Stick in the Buddhism: Mindfulness in the treatment of addiction and improved psychological wellbeing (Part 1)

Over the last year I’ve been receiving a lot of emails (well, about nine or ten to be honest but it seems like a lot) expressing surprise at the increasing numbers of papers on mindfulness that have been appearing on my Research Gate and Academia.edu webpages. This research program is actually being led by my friends and Nottingham Trent University research colleagues, Dr. Edo Shonin and Willliam Van Gordon. Given this increasing level of interest, I thought I would use my next two blogs to briefly overview some of these publications. My research colleagues and I are happy for anyone interested in these papers to contact us at the email addresses below. We also have a new book on the topic too (Mindfulness and Buddhist-derived Approaches in Mental Health and Addiction).

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Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). Cognitive Behavioral Therapy (CBT) and Meditation Awareness Training (MAT) for the treatment of co-occurring schizophrenia with pathological gambling: A case study. International Journal of Mental Health and Addiction, 12, 806–823.

  • There is a paucity of interventional approaches that are sensitive to the complex needs of individuals with co-occurring schizophrenia and pathological gambling. Utilizing a single-participant design, this study conducted the first clinical evaluation of a novel and integrated non-pharmacological treatment for a participant with dual-diagnosis schizophrenia and pathological gambling. The participant underwent a 20-week treatment course comprising: (i) an initial phase of second-wave cognitive behavioral therapy (CBT), and (ii) a subsequent phase employing a meditation-based recovery model (involving the administering of an intervention known as Meditation Awareness Training). The primary outcome was diagnostic change (based on DSM-IV-TR criteria) for schizophrenia and pathological gambling. Secondary outcomes were: (i) psychiatric symptom severity, (ii) pathological gambling symptom severity, (iii) psychosocial functioning, and (iv) dispositional mindfulness. Findings demonstrated that the participant was successfully treated for both schizophrenia and pathological gambling. Significant improvements were also observed across all other outcome variables and positive outcomes were maintained at three-month follow-up. An initial phase of CBT to improve social coping skills and environmental mastery, followed by a phase of meditation-based therapy to increase perceptual distance from mental urges and intrusive thoughts, may be a diagnostically-syntonic treatment for co-occurring schizophrenia and pathological gambling.

Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). The treatment of workaholism with Meditation Awareness Training: A case study. Explore: Journal of Science and Healing, 10, 193-195.

  • Recent decades have witnessed a marked increase in research investigating the etiology, typology, symptoms, prevalence, and correlates of workaholism. However, despite increasing prevalence rates for workaholism, there is a paucity of workaholism treatment studies. Indeed, guidelines for the treatment of workaholism tend to be based on either theoretical proposals or anecdotal reports elicited during clinical practice. Thus, there is a need to establish dedicated and effective treatments for workaholism. A novel broad-application interventional approach receiving increasing attention by occupational and healthcare stakeholders is that of third-wave cognitive behavioral therapies (CBTs). Third-wave CBTs integrate aspects of Eastern philosophy and typically employ a meditation-based recovery model. A primary treatment mechanism of these techniques involves the regulation of psychological and autonomic arousal by increasing perceptual distance from faulty thoughts and mental urges. A ‘meditative anchor’, such as observing the breath, is typically used to aid concentration and to help maintain an open-awareness of present moment sensory and cognitive-affective experience. The purpose of this case study was to conduct the first evaluation of a treatment employing a meditation-based recovery model for a workaholic.

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2013). Buddhist philosophy for the treatment of problem gambling. Journal of Behavioral Addictions, 2, 63-71.

  • In the last five years, scientific interest into the potential applications of Buddhist-derived interventions (BDIs) for the treatment of problem gambling has been growing. This paper reviews current directions, proposes conceptual applications, and discusses integration issues relating to the utilisation of BDIs as problem gambling treatments. A literature search and evaluation of the empirical literature for BDIs as problem gambling treatments was undertaken. To date, research has been limited to cross-sectional studies and clinical case studies and findings indicate that Buddhist-derived mindfulness practices have the potential to play an important role in ameliorating problem gambling symptomatology. As an adjunct to mindfulness, other Buddhist-derived practices are also of interest including: (i) insight meditation techniques (e.g., meditation on ‘emptiness’) to overcome avoidance and dissociation strategies, (ii) ‘antidotes’ (e.g., patience, impermanence, etc.) to attenuate impulsivity and salience-related issues, (iii) loving-kindness and compassion meditation to foster positive thinking and reduce conflict, and (iv) ‘middle-way’ principles and ‘bliss-substitution’ to reduce relapse and temper withdrawal symptoms. In addition to an absence of controlled treatment studies, the successful operationalisation of BDIs as effective treatments for problem gambling may be impeded by issues such as a deficiency of suitably experienced BDI clinicians, and the poor provision by service providers of both BDIs and dedicated gambling interventions. Preliminary findings for BDIs as problem gambling treatments are promising, however, further research is required.

Shonin, E.S., van Gordon, W., Slade, K. & Griffiths, M.D. (2013). Mindfulness and other Buddhist-derived interventions in correctional settings: A systematic review. Aggression and Violent Behavior, 18, 365-372.

  • Throughout the last decade, there has been a growth of interest into the rehabilitative utility of Buddhist-derived interventions (BDIs) for incarcerated populations. The purpose of this study was to systematically review the evidence for BDIs in correctional settings. MEDLINE, Science Direct, ISI Web of Knowledge, PsychInfo, and Google Scholar electronic databases were systematically searched. Reference lists of retrieved articles and review papers were also examined for any further studies. Controlled intervention studies of BDIs that utilised incarcerated samples were included. Jaded scoring was used to evaluate methodological quality. PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines were followed. The initial comprehensive literature search yielded 85 papers but only eight studies met all the inclusion criteria. The eight eligible studies comprised two mindfulness studies, four vipassana meditation studies, and two studies utilizing other BDIs. Intervention participants demonstrated significant improvements across five key criminogenic variables: (i) negative affective, (ii) substance use (and related attitudes), (iii) anger and hostility, (iv) relaxation capacity, and (v) self-esteem and optimism. There were a number of major quality issues. It is concluded that BDIs may be feasible and effective rehabilitative interventions for incarcerated populations. However, if the potential suitability and efficacy of BDIs for prisoner populations is to be evaluated in earnest, it is essential that methodological rigour is substantially improved. Studies that can overcome the ethical issues relating to randomisation in correctional settings and employ robust randomised controlled trial designs are favoured.

Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). Mindfulness meditation in American correctional facilities: A ‘what-works’ approach to reducing reoffending. Corrections Today: Journal of the American Correctional Association, March/April, 48-51.

  • Throughout the last decade, there has been a growth of interest into the rehabilitative utility of Buddhist-derived interventions (BDIs) for incarcerated populations. The purpose of this study was to systematically review the evidence for BDIs in correctional settings. MEDLINE, Science Direct, ISI Web of Knowledge, PsychInfo, and Google Scholar electronic databases were systematically searched. Reference lists of retrieved articles and review papers were also examined for any further studies. Controlled intervention studies of BDIs that utilised incarcerated samples were included. Jaded scoring was used to evaluate methodological quality. PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines were followed. The initial comprehensive literature search yielded 85 papers and but only eight studies met all the inclusion criteria. The eight eligible studies comprised two mindfulness studies, four vipassana meditation studies, and two studies utilizing other BDIs. Intervention participants demonstrated significant improvements across five key criminogenic variables: (i) negative affective, (ii) substance use (and related attitudes), (iii) anger and hostility, (iv) relaxation capacity, and (v) self-esteem and optimism. There were a number of major quality issues. It is concluded that BDIs may be feasible and effective rehabilitative interventions for incarcerated populations. However, if the potential suitability and efficacy of BDIs for prisoner populations is to be evaluated in earnest, it is essential that methodological rigour is substantially improved. Studies that can overcome the ethical issues relating to randomisation in correctional settings and employ robust randomised controlled trial designs are favoured.

Contact details

e.shonin@awaketowisdom.co.ukwilliam@awaketowisdom.co.ukmark.griffiths@ntu.ac.uk

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Additional input by Edo Shonin and William Van Gordon

Further reading

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2012). The health benefits of mindfulness-based interventions for children and adolescents, Education and Health, 30, 94-97.

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2013). Mindfulness-based interventions: Towards mindful clinical integration. Frontiers in Psychology, 4, 194, doi: 10.3389/fpsyg.2013.00194.

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2013). Buddhist philosophy for the treatment of problem gambling. Journal of Behavioral Addictions, 2, 63-71.

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2013). Meditation as medication: Are attitudes changing? British Journal of General Practice, 617, 654-654.

Shonin, E., Van Gordon, W. & Griffiths, M.D. (2013). Mindfulness and addiction: Sending out an SOS. Addiction Today, March, 18-19.

Shonin, E., Van Gordon, W. & Griffiths, M.D. (2013). Mindfulness-based therapy: A tool for spiritual growth? Thresholds, Summer, 14-18.

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2014). Practical tips for using mindfulness in general practice. British Journal of General Practice, 624 368-369.

Shonin, E.S., van Gordon, W. & Griffiths, M.D. (2014). Meditation Based Awareness Training (MBAT) for psychological wellbeing: A qualitative examination of participant experiences. Journal of Religion and Health, 53, 849–863.

Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). Mindfulness meditation in American correctional facilities: A ‘what-works’ approach to reducing reoffending. Corrections Today: Journal of the American Correctional Association, March/April, 48-51.

Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). Does mindfulness meditation have a role in the treatment of psychosis? Australian and New Zealand Journal of Psychiatry, 48, 124-127.

Shonin, E., Van Gordon W., & Griffiths M.D. (2014). The emerging role of Buddhism in clinical psychology: Towards effective integration. Psychology of Religion and Spirituality, 6, 123-137.

Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). The treatment of workaholism with Meditation Awareness Training: A case study. Explore: Journal of Science and Healing, 10, 193-195.

Shonin, E.S., Van Gordon, W. & Griffiths, M.D. (2014). Mindfulness and the Social Media, Mass Communication and Journalism, 4: 194. doi: 10.4172/2165-7912.1000194.

Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). Cognitive Behavioral Therapy (CBT) and Meditation Awareness Training (MAT) for the treatment of co-occurring schizophrenia with pathological gambling: A case study. International Journal of Mental Health and Addiction, 12, 181-196.

Shonin, E., Van Gordon, W., & Griffiths, M.D. (2016), Mindfulness and Buddhist-derived Approaches in Mental Health and Addiction. New York: Springer.

Shonin, E.S., van Gordon, W., Slade, K. & Griffiths, M.D. (2013). Mindfulness and other Buddhist-derived interventions in correctional settings: A systematic review. Aggression and Violent Behavior, 18, 365-372.

Shonin, E., Van Gordon W., & Griffiths, M.D. (2014). Are there risks associated with using mindfulness for the treatment of psychopathology? Clinical Practice, 11, 389-392.

Van Gordon, W. Shonin, E.S., Skelton, K. & Griffiths, M.D. (2014). Working mindfully: Can mindfulness improve work-related wellbeing and work? Counselling at Work, 87, 14-19.

Van Gordon, W., Shonin, E., Sumich, A., Sundin, E., & Griffiths, M.D. (2014). Meditation Awareness Training (MAT) for psychological wellbeing in a sub-clinical sample of university students: A controlled pilot study. Mindfulness, 12, 806–823.

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.