Internet game addiction is becoming a serious problem in countries such as the
United States or South Korea which have wide access to the Internet. The definition
of Internet game addiction varies. Young (1996) defines Internet addiction as
"centralization of use of the Internet at the expense of other activities" and "putting
priority on maintaining electronic relationships." DSM-V defines Internet addiction as:
1) excessive use, often associated with a loss of sense of time or a neglect of basic
drives; 2) withdrawal, with feelings of anger, tension, and/or depression when the
computer is inaccessible; 3) tolerance, with the need for better computer equipment,
more software, or more hours of use; and 4) negative repercussions, with arguments,
lying, poor achievement, social isolation, and fatigue (American Journal of Psychiatry,
2008). The prevalence of Internet addiction in South Korea varies from 2.3% in high
school students (Choi et al., 2009) to 20.3% in adolescents (Ha et al., 2006). The
prevalence of Internet abuse is 47% in high school students. Students with Internet
addiction used the Internet for 3.5 hours (+/-2.4) per day, while non-addicted students
used the Internet for 1.7 hours (+/-1.2) per day (Choi et al., 2009). A survey reported
that 15% of 1,527 adolescents were classified as risky internet users. The more
severe the Internet addiction, the more the use of games: 75.3% of the high-risk
group used the Internet for games (Korea Agency for Digital Opportunity and
Program, 2005). The prevalence of Internet addiction in the United States is from
0.3% in the general population (Shaw & Black, 2008) to 25% in undergraduate
students (Fortson, Scotti, Chen, Malone, & Del Ben, 2007). Widyanto and McMurran
(2004) reported that 86 young adults (mean age 28) spent 20 hours per week on the
Internet for personal use.
Game addiction has negative effects such as loss of interpersonal relationships, failure
to address responsibilities, distraction from other aspects of life, and poor health
(Steward, 2004). Related factors of game addiction include hostility (Chiu, Lee, &
Huang, 2004), little or no self-confidence (Griffiths, 2000), depression (LaRose, Lin, &
Eastin, 2003), loneliness (Nalwa & Anand, 2003), low self-esteem, stress,
impulsiveness (Cho & Lee, 2004), and low self-control (Song, 1998). Interventions for
Internet game addiction include a value facilitation program (Jang, 2005), cognitivebehavioral therapy to increase self control (Lee, 2005), a self-growth program (Oh,
2004), self-control training (Kim, 2004), and a game desire control program (Pyo, 2003).
Even though the effects of a 12-step program were evaluated on drug addiction, they
were not evaluated on game addiction (Kristensen & Vederhus, 2005). Therefore, the
purpose of this study is to describe a case study of a pilot intervention using a 12-step
program combined with behavior modification and cognitive-behavior therapy to treat
Internet game addiction in an adolescent.
Cognitive-behavioral therapy, a 12-step program, and behavior modification have all
been reported as assisting in changing patients' unhealthy behaviors. Cognitive
behavioral therapy intends to change behaviors by changing beliefs. Individuals are
required to analyze emotion, thought, behavior, and others situations when patients
involve themselves in unhealthy behaviors. Individuals are required to analyze any
underlying beliefs that may be untrue, unrealistic, or counterproductive (Magill & Ray,
2009). A 12-step program uses an informal bio-psycho-social-spiritual model (Craig,
1993). In 1996, the American Society of Addiction Medicine reported that a 12-step
program demonstrated the ability to identify the problem, define the solution, and
design a program of actions necessary to bring about recovery (Fajardo, 2006).
Behavior modification modifies behaviors using reinforcement, punishment, and
extinction (eliminating the incentives for unwanted behavior) based on a learning
theory that every behavior is learned by external conditions and learned behaviors
are cancelled by learning. Token economy, which is designed to maximize effects in
groups, helps a group gain tokens by acting out adaptive behaviors and encourages
them to do more adaptive behaviors by exchanging tokens with a primary reinforcing
agent (Lim, 2001).
A 16-year-old Korean adolescent, HC, was referred by his mother because of his
negative attitude, depression, and overuse of the Internet. Even though he did not
want to come to the US to live or study, his parents persuaded him to come here with
his mother and brother. He has been in the US for 4 years. After coming to the US,
he had difficulty speaking English. He withdrew from his friends. He started playing
Internet games at the age of seven. The hours for playing games increased rapidly
because he spent a lot of time alone after coming to the US. On the other hand,
Koreans think manners are very important, especially between older and younger
generations. While Americans call each other "you" regardless of their age, Koreans
have many different words for expressing respect. HC has poor social relationships
with his brother and Korean seniors because he does not use those respectful words.
His mother worried about his negative attitude toward his father. For example, when
his father visited him from Korea, and his father suggested something to do together,
he usually answered negatively. HC expressed his need to reduce the hours of using
games. He spent 3 to 5 hours on playing games on weekdays and 13 hours on
weekends. He said that it was difficult to control, especially on weekends.
THE PROCESS OF INTERVENTION
Counseling consisted of five individual sessions that ranged in length from 30
minutes to 1 hour per week. Homework assignments were used to record HC's
activities and how he spent his time. Thoughts, emotions, and behavior that helped to
control his desire to play games were explored. The counselor and HC discussed
how to manage his time during the week and stickers were used as a reward when
he kept his promise. Discussion using one or two questions based on a 12-step
program took place (On-line game anonymous, 2006). In every meeting, he
explained what he did well in the last week. A contract was made to teach him
accountability. If he was not on time, he paid one dollar per every 10-minute period
he was late.
The first session focused on obtaining a general assessment. The second session
focused on the assessment of game addiction and creating a contract for behavior
modification. HC agreed to try to reduce the time spent on games and increase time
spent on other healthy activities. It was explained that stickers would be given as
positive reinforcement and a prize would be given when he gathered an agreed-upon
amount of stickers during eight sessions. His mother promised to give him half the
money he needed for a new computer if he reached his goal. The contract was in
written form and signed by HC, his mother, and a counselor (Table 1). Also, HC was
asked to record the time spent on games and alternative activities on paper (Table
2). In the third session, his mother said that he had decreased game-playing time but
showed agitation because of reducing the time spent on games. He spent less than 1
hour per a day on weekdays, but spent over 3 hours per day during the weekend. On
a weekend, he did not go to school and did not have anything to do. He tried to talk
with his mother and watched television dramas instead of playing games. He
received 5 stickers for reducing his game time and 20 stickers for engaging in healthy
activities. In the fourth session, he reached his goal for only 2 days. He said that he
woke up early, did homework, fared well on his exam, and exercised. He got two
stickers for reducing game time, but he could not remember spending time on healthy
activities. He skipped two sessions because he slept late in the morning. His mother
said that he sat up all night hanging out with his friends. In the fifth session, he did
not reach his goal for even 1 day. He spent over 3 hours on games every day, but he
tried to spend time on basketball, talking, and bowling with friends. He explained that
he did not come the last 2 weeks because he thought it was too much trouble and the
place for counseling was far away from his house. He was asked whether he had a
desire to continue counseling or not. He avoided giving an answer directly. He was
given 1 week to think about this. After contacting the counselor, finally he said that he
wanted to give up.
HC was encouraged to be conscious of how his time was spent more on games than
he intended and to explain which emotions, thoughts, and behaviors contribute to
overuse of games. He was encouraged to think about which factors were helpful in
reducing time spent on games. HC was asked to record his thoughts, emotions, and
behaviors related to games on a form each week (Table 3). In the second session,
discussion centered on the reasons, and disadvantages of playing games, methods
to use to decrease time spent on games, and how to increase his holistic health. He
played online games because it was fun; he could meet people through online
games, and feel satisfaction when he reached the goals of game scores. He wanted
to reduce time on computer games because it interfered with his studying and was
not good for his health. In the third session, a screening tool for measuring his game
addiction was given because he did not accept that he was addicted to computer
games. He thought that if he wanted, he could stop. He was encouraged to express
emotions, thoughts, and behaviors related to games. He always felt bored at home.
When he felt bored, he usually played computer games. He could not drive. His
mother and brother were usually outside until the evening or later and he was often
alone on weekdays. Those situations contributed to his game addiction. In the fourth
session, he forgot to bring his homework. He expressed feeling burdened to do his
counseling homework. The idea of cognitive-behavioral therapy was good, but it was
difficult for him to practice daily. As time went by, he had difficulty accurately writing
down his exact hours on different activities. In addition, two pieces of paper every
week were given: one for recording his activities and time, another for recording his
emotions, thoughts, and behaviors related to games. It was difficult for him to keep
the records and bring them to the sessions.
The main issue for him was managing his boredom. A suggestion was given for him to
do something different with his time. After the fifth session, he started to learn golf and
he was becoming more interested in golfing. Therefore, he could reduce his time on
games. He and his mother were encouraged to spend time outside doing something
such as playing golf.
Questions for each session were made based on the 12-step program (On-line game
anonymous, 2006) (Table 4). For example, the goal of the first session was "we
admitted we were powerless over on-line gaming and that our lives have become
unmanageable." The counselor offered three questions to approach this goal. "Which
part is difficult for you to control?" "Which part is easy for you to control?" and "Have
you despaired about your failure of self-control?" He doubted the existence of God
because he prayed for something but God did not answer. Therefore he doubted God
could help with his problems. He did not feel the need to pray. In the fourth session,
what harm he caused to others was discussed. He said that he lied often in online
games to sell his items at a high price. He said that he used abusive words because
his friend used those words. He said he would try to reduce abusive words. He was
encouraged to apologize to people whom he harmed by lying and using abusive
words. In the fifth session, demerits in his character were discussed. He said that he
felt difficulty accepting authority figures, often used abusive language, had
perfectionism, and played games excessively. He thought that his perfectionism
contributed to game addiction because he made a goal for game scores and he
wanted to reach the goal. He was encouraged to think about the reasons he had
difficulty having relationships with older persons. He heard that he should use
respectful language and manners when he met Koreans. He said that he did not want
to behave differently between Americans and Koreans. He felt that it was like having
a dual personality. His counselor empathized that he would have difficulty living with
the expectations of two cultures. He was encouraged to think about other's
perspectives. To have a good relationship with others, his counselor explained a
need to act differently according to different cultural norms.
RESULT OF THE INTERVENTION
The program consisted of eight sessions originally. However, the counseling stopped
after five sessions. During the counseling, there was some improvement. However,
HC did not do his homework and did not keep his promise to reduce game hours. In
the 2-month follow-up, his mother said that he had reduced his game time since he
started golfing with her.
There are not many studies for intervention of Internet game addiction published in
English. Young (2007) reported that cognitive behavioral therapy for eight sessions
helped 114 middle-aged male patients to control Internet addiction. Collier (2009)
introduced an inpatient therapy which consists of talk therapy, life-skills coaching,
physical and nutritional education, work and home-maintenance skill-building, 12step meetings, and feeding goats and chickens. There is no report of the effect of this
program. Shek, Tang, and Lo (2009) reported the effect of an Internet addiction
intervention program which consisted of a motivational interview, individual
counseling, a peer support group, and family-based counseling. The authors reported
that this Internet addiction problem decreased in 59 participants after participating in
the program for 15-19 months. Further studies are needed to develop interventions
for Internet addiction and examine the effects.
Just as with other diseases, prevention is more important than treatment in the case
of Internet addiction. Ko, Yen, Chen, Yeh, and Yen (2009) reported that attentiondeficit/hyperactivity disorder, hostility, depression, and social phobia were predictors
of Internet addiction. Therefore, screening attention-deficit/ hyperactivity disorder
(ADHD), depression, hostility, or social phobia among children and adolescents is
important to prevent Internet addiction. Medications are needed when depression or
ADHD coexist with Internet addiction. Family intervention is needed to prevent
Internet addiction. Park, Kim, and Choi (2008) reported that parenting attitudes,
family communication, family cohesion, and family violence exposure were
associated with Internet addiction. In this case, there was a lack of communication
between the participant and parents. Education and counseling for parents is also
important to prevent Internet addiction. For example, parents need to know how to
have healthy communication with children, to have regular communication with their
children, to check which Web sites their children often access. Parents have to put
the computer in the living room not in the children's room and encourage healthy
outdoor activities. For the best result from counseling intervention, group therapy
would be better than individual psychotherapy because adolescents tend to pursue
fun with friends.
LIMITATIONS AND RECOMMENDATIONS
The burden of homework in cognitive-behavior therapy might cause subjects to resist
participation in the counseling. To increase participation, the therapist could assign
homework one day per week. Providing a binder for record-keeping would help the
subject to remember to bring the homework to the session. The most important
reason for HC stopping the sessions could be that this counseling was not fun for
him. He had previously experienced having group therapy for ten sessions with
friends. At that time he wanted to continue the group therapy and he showed interest.
Group therapy would be more effective for Internet game addiction. The length of
time for counseling is also important because addiction recovery is not easy to
accomplish in a short period of time. At least eight sessions would be helpful for a
game addiction problem (G. H. Kim, 2003; J. H. Kim, 2003)
PSY 200 Case Study Milestone Two Guidelines and Rubric
In the previous milestone, you focused on addiction and its effects. In Milestone Two, you will want to focus on the assessment used as well as the addiction.
Read this case study and write a short paper in which you address the following critical elements:
Case study client information and presenting problem
o Identify the client (gender, age, race, profession).
Identify the addiction that this client presents with.
Does he have a substance addiction, like alcohol, prescription drugs, or illicit drugs?
Does he have a process addiction, like gambling, video gaming, or shopping?
o Identify the physiological procedure the client uses for administration of his addiction (oral, injection, watching videos, phone calls).
o Describe the type of environment in which the client spends his time.
Is there support within the family?
Does the client hang around with friends who are using addictive substances?
Is the client working for a company where his addiction is encouraged?
o What is the client’s philosophical stand about his addiction?
What is his motivation level for getting help?
Is there a sense of hope or hopelessness?
o Provide the history of the addiction. (Is it a substance or process addiction?)
What is the history of the addiction? Remember, there are many types of addiction, and not all were defined around that time. For
example, video game addiction was not officially defined until 1995, while alcohol addiction was defined in 1941.
o Differentiate between the physiological and psychological effects of the addiction.
Does the addiction physiologically affect the client’s behaviors and mental processes? If so, how?
Does the addiction psychologically affect the client’s behaviors and mental processes? If so, how?
o Discuss the results of this case.
Did the client respond positively to the treatment?
Did the client relapse?
Guidelines for Submission: This submission should follow APA formatting guidelines, use 12-point Times New Roman font and 1-inch margins, be at least 3
pages in length, not including the title page and references page, and employ a minimum of 2 scholarly sources that directly support your main ideas.
Case Study Milestone Two Rubric
Meets “Proficient” criteria, and
analysis of the client is extensive
and imperative to the case study
Meets “Proficient” criteria and
utilizes relevant examples to
Provides a complete background
history of the client
Needs Improvement (55%)
Provides an incomplete
background history of the client
Not Evident (0%)
Does not provide background
Discusses the physiological
procedure client uses to
administer his addiction, the
environmental elements the
client is affected by, and the
client’s philosophical stand
about his addiction
Does not provide addiction
Meets “Proficient” criteria and
uses specific, relevant examples
to substantiate claims through
the synthesis of the scholarly
Meets “Proficient” criteria and
uses specific and releva ...
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