Teens taking Facebook breaks together

I think it's not so much taking a break from technology as it is from high school drama – though social networking does make it easy to have the drama in their faces 24/7, if they allow it to. The New York Times tells of two high school juniors in San Francisco who, "by mutual agreement," allow themselves to log on to Facebook only the first Saturday of each month. "The two are among the many teenagers, especially girls, who are recognizing the huge distraction Facebook presents – the hours it consumes every day, to say nothing of the toll it takes during finals and college applications, according to parents, teachers and the students themselves," the Times reports. Some deactivate their accounts, others form support group (not Facebook groups!) to help each other stay away. The Times cites the view of a psychologist and "Internet addiction" center director that Facebook's just like any other addiction. I'm no psychologist, but I do think it might be partly the real-life reality TV of school life that's addictive. On p. 2 of the article, the view of educator and author Rachel Simmons seems to agree when she refers to how hard it can be for teens to turn away from the sort of ticker tape of their social circle represented by Facebook's News Feed when they're "obsessed" with where they stand in that "social landscape." I'm impressed with the initiative they're taking (are they feeling that reflection time is healthy and acting on that?). But I wonder if, by creating agreements and forming support groups they're any less tethered to each other (see MIT sociologist Sherry Turkle's "Always-On/Always-On-You: The Tethered Self") and using technology that much less. Do they not need texting and talking on mobile phones to maintain pacts and check up on each other? Still, I'm sure there are some adults just as addicted to drama who could take a queue from these high school students.

US's first Net-addiction center

The Internet addiction center, called ReSTART, is in Fall City, Washington, about 30 miles east of Seattle. It offers a $14,000, 45-day program designed to help people (six at a time) end their addictions to "pathological computer use, which can include obsessive use of video games, texting, Facebook, eBay, Twitter and any other time-killers brought courtesy of technology," according to an article in the Washington Post. The founders, therapists, say they've been helping patients with Net addiction for years on an out-patient basis. "Internet addiction is not recognized as a separate disorder by the American Psychiatric Association, and treatment is not generally covered by insurance. But there are many such treatment centers in China, South Korea and Taiwan - where Internet addiction is taken very seriously - and many psychiatric experts say it is clear that Internet addiction is real and harmful," according to the article. Some sources say obsessive use of technologies is a sign of other disorders such as depression, anxiety, or "social phobic symptoms," issues that "make it hard for them to live a full, balanced life and deal face-to-face with other people."

China's definition of Net addiction

Sheer critical mass could be one reason why Chinese doctors had to come up with a definition of Internet addiction. Net users aged 18-30 make up half of China's estimated online population of some 250 million people, and 10% of that group of Netizens are addicted (about 70% of them male), China Daily reports. That's 12.5 million addicts. The announcement, by Dr. Tao Ran of Beijing's Military General Hospital, was one of two firsts for China: the first diagnostic definition of Internet addiction "amid efforts to address an increasing number of psychological problems that reportedly result from Internet overuse" and China's first Internet addiction clinic. "China could become the first country to classify Internet addiction as a clinical disorder and plans to lead the world by registering the condition with the World Health Organisation," the Times of London reports. Symptoms include "yearning to get back online, mental or physical distress, irritation and difficulty concentrating or sleeping." Dr. Tao "classifies as addicts those who spend at least six hours online a day and have shown at least one symptom in the past three months." He said 80% can be cured with treatment that "usually lasts about three months." The Times adds that "research by the internet media company InterActiveCorp showed that 42% of Chinese youngsters polled felt addicted to the internet, compared with 18% in the US."

Don't just take away the Xbox: Psychiatrist's view

The details emerging from a tragic national story about a missing boy in Canada point to an important observation about videogaming: that taking away a videogame (or device it's played on) does not have the same effect as taking away a toy or conventional game. Fifteen-year-old Brandon Crisp of Barrie, Ontario, missing for more than two weeks, left the house angry after his father took away his Xbox console. His father told the Toronto Globe and Mail that "this has become his identity, and I didn't realize how in-depth this was until I took his Xbox away." His mother "would wake in the middle of the night to hear ... Brandon, speaking into his headset as he feverishly played [the Xbox game] 'Call of Duty 4: Modern Warfare'," the Globe and Mail reports in another article, adding that his parents are "sure Brandon had become addicted to the game and link its appeal" to his disappearance.

Portland, Ore.-based psychiatrist Jerald Block emailed me a heads-up about this story last weekend. So I took the opportunity to ask him, one of the US's leading experts on videogame addiction, how this kind of addiction can be treated - what I can tell parents about that. He started and ended with that question, but in the middle of his answer are some very helpful insights for anyone who cares about or works with an addicted gamer - parents, friends, educators, policymakers - into the impact that sudden removal from a videogame's world can have....

Why game addiction's hard to treat

How to treat this addiction is "a good question," Dr. Block wrote me, "and one that I hate because it has no easy answer. I have treated many cases and I am still trying to figure out what works best and for whom. But here's what I've learned about gaming in general and gamers of all ages: Gaming is particularly hard to treat as it is 1) enjoyable, 2) an outlet for despair/anger/sex, 3) readily available, 4) time-consuming and thus fills in otherwise unpleasant 'spaces' in one's life, 5) a social forum with Virtual or simulated people, 6) a source of power, and 7) a portrayal of a fair, equal world.

"When people elect to voluntarily give all that up, they generally struggle with their mood and anger. If they are *forced* to give it up, all those emotions become amplified; any fanciful notions of power or control are trampled when they're disconnected against their will.

"Also, unplugging the computer can vividly demonstrate how intangible and fragile the Virtual is and can lead to existential crisis. This is a complex concept, but I consider it crucial. People are spending 30, 40, 50, or more hours a week powering up and getting success on their computers. They work hard at mastering the games and technology. They make significant sacrifices in terms of time and effort. The mastery becomes representative, in a psychological sense, of one's self-worth.

What is reality?

"Now disconnect the computer or console. You have summarily dismissed those accomplishments - the fantasy, the power, and that alternate life, heavily invested in (and mind you sometimes that alternate life may seem a whole lot better than the Real one). Now take it a step further: If someone could so easily destroy such an important thing that, although Virtual, seemed quite Real, isn't it also possible that our flesh-and-blood reality is yet another deception or illusion? To gamers - given the story lines they 'live' in - this is not as far-fetched as it may sound. Philosophers and religious leaders have discussed this for hundreds of years. It does sound pretty disturbing (or disturbed) - the concept that we might not actually exist but are, instead, merely some other being's dream or, as Oxford philosopher Nick Bostrom recently wondered, merely simulations running in a simulated society? Such concepts can sound bizarre, but when in history have people actually been able to live them in very real-seeming environments - on so massive a scale, and at such young ages? More than 10 million people worldwide regularly play World of Warcraft, and that's just one such environment/game. I doubt the concept that life might actually be yet another illusion is hardly foreign to WoW's players. It is actually commonplace enough, the subject of numerous films (e.g., The Matrix) and even parody (The Onion's 'World of World of Warcraft' video).

"What I am getting at, here, is that - whatever your philosophy happens to be about how we define 'reality' - I believe the more one starts to believe he or she exists only as a piece of code running in some meta-computer (as some of my patients have done), the less valuable life becomes - your own life, others' lives, and the ethics by which you live. If one's life isn't real and one is just a puppet in some meta-being's 'game,' then it can come to feel like what one does in Real Life doesn't matter much.

Understanding the gamer's needs

"These are some of the risks of abruptly stopping computer or videogame use. As for treatment, one option is to cut someone off in the context of an extended (2+ weeks) camp where he or she is left physically or mentally exhausted. In doing so, you are wisely substituting rewards in the Real for those being lost in the Virtual. For example, at a well-structured camp, there are not an extra 30 hours to fill each week after work or school, and people form relationships with others who are enduring the same hardships. If it sounds something like boot camp in the military ... well, depending on your age, that is a therapeutic option worth considering.

"The alternative to 'cutting the cord' is to talk with the person and try to understand his perspective. Maybe he thinks his gaming is more helpful than harmful, maybe not a problem at all. So, first come to understand what the patient feels. If you feel the computer use is counterproductive and she doesn't, discuss why the two of you seem unable to understand one another's perspectives. Nothing will happen until she becomes motivated to change herself. If, eventually, the patient comes to believe as you do - that the computer or game use is excessive and destructive - then you can try to agree on goals to cut back on it. Part of that discussion will entail trying to address what needs the computer was satisfying and what one can do instead.

"The process tends to be very gradual - progress is measured in weeks or months - and it is therapy-intensive. Obviously, it is not the 'quick fix' that we want and need. What do I suggest parents do? I don't honestly know. If it were my child, I would first start by setting limits. I would avoid cutting him off from his technology for more than a few consecutive days and would avoid using computer restrictions punitively. If limit-setting failed and the compulsive play got worse, I would punt and take him to see a therapist."

Related links

"Virtual games, real addiction" in the Toronto Globe and Mail

"$50,000 reward for helping to find missing Ontario teen" in the National Post

"Missing teen hooked on Xbox game" at CNET

"Missing Ontario teen may not be in Canada: Police" at CBC News

Dr. Block's site

"West slow to take on Net addiction"

"'SIGNS' of Net addiction"

West slow to take on Net addiction: Psychiatrist

Nine computer games are purchased every second in the US; two-thirds of Americans, or around 200 million people, play videogames; 2% of US gamers, or about 4 million people, "are heavy users" averaging around 40 hours of play a week; and 66 million (a third) play around 20 hours/week. That's data cited by Jerald Block, an Oregon-based psychiatrist, in British cultural and political magazine The Standpoint. He's writing about Internet addiction, "or the more accurate and general term Pathological Computer Use (PCU)," which he says is "not an established diagnosis but one that might be included in the next version of the mental-health diagnostic guidebook, the DSM-V," which will be out in 2012. A doctor in the US or Europe would probably not know what to do with the information that you're spending 40+ hours a week playing videogames. "Dealing with such matters is not part of our training," Dr. Block writes. "In Asia, however, you would probably get a psychiatric diagnosis. Because doctors in Asia … recognise excessive computer use as a serious issue." Block goes on to describe what PCU patients' symptoms and behaviors are like from a physician's perspective, including a description of what virtual-reality "cybering" can now be like and addicts' unsettlingly, progressively blurry distinction between reality and virtual reality.

But all that's about diagnosis, he writes in his conclusion. Treatment is an entirely different, very difficult proposition. "The uncomfortable truth is that our treatment strategies [worldwide] for this malady are inadequate and often fail. Until we learn more or have better clinical tools, our best approach may be to work on prevention." [See also "'SIGNS' of Net addiction: Interview."]

'SIGNS' of Net addiction: Interview

Last year a person who works for a psychiatric hospital and specializes in adolescent care posted in our forum at ConnectSafely.org asking if anyone had developed screening for "Internet addiction." No one in the forum had, and I suspected this person was pioneering something, pointing to a challenge for social services and the health care profession for which there is little research. It has since occurred to me to put this question to Dr. Jerald Block, a psychiatrist in Portland, Ore., who has worked with patients on game addiction.

Here's our email conversation, illustrating the challenges this question poses to the medical profession (but stick with him, parents, because below the challenges is some helpful thinking for you):

NetFamilyNews: "Have you ever put together a screening list for 'Internet addiction' and 'online porn addiction' - what a parent or caregiver might look for to decide if a child needs help toward a better balance of activities? I'm sure there's the usual sleeplessness, suffering grades, etc., but I'd appreciate a comprehensive list if you have one. 'Game addiction' too - all three would be great, but especially this blanket term we're hearing, 'Internet addiction'."

Dr. Block: "I've given this a lot of thought and it is more difficult than I'd like to admit. I have made my own 'testing instrument' to detect 'Pathological Computer Use,' but it has not been 'standardized.' That is, essentially, the issue.

"Lacking clear diagnostic criteria, we also lack a scientific test. Also, even using proposed criteria, we still need to compare the test to the gold standard - a clinical interview. You have to do this with a great many people, and that many interviews cost money. It also takes effort to find the representative patients.

"The only people that have done this that I trust are the South Koreans, who have spent bundles on the issue, and some psychiatrists in Taiwan. Their clinical test has been standardized against and compared to the clinical interview. And, they have a variant that is meant to be used by the parent. However, the test is culture-specific and would not translate well to computer use in the US. [For a solid look at cultural differences in social Web use between the US and Korea, see this article about Korean social networking in the Journal of Computer-Mediated Communication.]

"That being said, I use a mnemonic to identify 'SIGNS' in at-risk people (kids or adults):

S = Sleep cycle is consistently advanced. Goes to sleep later and wakes later or is tired in the morning.
I = Irritable when not on the computer. Preoccupied thinking about the computer and their activities there (sex, gaming, browsing, tuning the system up, etc.). Can become enraged if told to stop using.
G = Guilty about his/her computer use so tries to hide evidence of 1) game/porn purchases, 2) online activities (deletes cache, uses encryption/passwords, etc.), and 3) logs on secretly, etc.; 4) defensive when confronted.
N = Nightmares. Dreams about his or her gaming/computer use.
S = Social dropouts - people who become more isolated by their computer use. This is seen when there is a consistent pattern of sacrificing real-life relationships to preserve virtual ones. Alternatively, seems to prefer living in virtual worlds more than their real one. These people become NEETs: 'Not in Employment, Education, or Training.'

"If one or more of these questions are answered 'yes' AND the person is having interpersonal problems, he/she is at risk."

NetFamilyNews: Following up, I asked Dr. Block, "Would you say the SIGNS mnemonic is for both 'computer addiction' and 'Internet addiction'?"

Dr. Block: "Yes. I consider Internet addiction a subset of PCU (pathological computer use), and the mnemonic screens for PCU."

NetFamilyNews: "Would it cover videogames and social-networking sites as well?"

Dr. Block: "Yes, I believe so."

NetFamilyNews: "If kids are at risk for one of these types of addiction, what do you recommend a parent do? Consider taking the child to a clinical psychologist or family therapist?"

Dr. Block: "I really don't know. I don't think anybody does. I would suggest that parents try to handle the situation themselves, initially. If that fails, I would consult a professional. The problem is that most professionals do not know what to do and are unacquainted and unequipped to manage the issue. In my experience, PCU is underdiagnosed, hard to treat, comorbid with other disorders, and often subject to relapse. Treatments tend to be long-term and, frankly, expensive. And clinical results are less than stellar. That is the international experience, not just the US's. It is a serious clinical problem, from many perspectives.

"An easier question is what NOT to do. DO NOT "cut the cord" unless in the context of an extended rehab-like setting. Cutting the child/adult off [from the computer, game, social-networking activity] can produce far worse outcomes (drug use, violence, depression, etc.). I differ in this from some practitioners who advocate for setting such firm limits. [See his commentary on this in the Rocky Mountain News or full-length analysis in "Related links" below.]

"Incidentally, probably the most effective treatment would be a 'retreat' or rehab-like setting for a minimum of 2 weeks. I think a full month is better [see this New York Times piece about a South Korean Internet addiction rehab camp]. But that is expensive and many would see it as overkill."

NetFamilyNews: "What do you think of applying the word 'addiction' to these non-chemical activities, or can they have a chemical impact on the brain?"

Dr. Block: "There is the concept of 'positive addictions' - people like 'workaholics,' avid readers, or model railroaders. At times, PCU might be more productive and be considered in that way (like for people employed in the industry, i.e., video game programmers).

"More generally, I think there is a common pathway with substance abuse. The issues around craving and the later phases of withdrawal appear to be very similar.

"That said, I avoid the use of the word 'addiction.' It is just too explosive, political, and packed with other meanings. I prefer to think of this as a compulsive-impulsive spectrum disorder, much like compulsive eating, gambling, pyromania, and trichotillomania."

Related links

Dr. Block's Web site

His editorial "Internet Addiction" in the latest issue of the American Journal of Psychiatry

"Net addiction rehab in Korea"

"Lessons from Columbine: Virtual and Real Rage," the last bullet under Computer Related - Research on Dr. Block's home page, makes reference to the teen shooters' home and school environments, and other detailed analysis

"Notable fresh videogame findings" (under this headline, the items "Columbine revisited" and "Pathological videogame use" link to findings on these subjects by Dr. Block).

Net-addiction rehab in Korea

It's South Korea's first "Internet addiction" rehab camp and it may be the first in the world too. The Jump Up Internet Rescue School is "part boot camp, part rehab center [and] resembles programs around the world for troubled youths," the New York Times reports. "Drill instructors drive young men through military-style obstacle courses, counselors lead group sessions, and there are even therapeutic workshops on pottery and drumming." The incredible accessibility of broadband Internet in Korea, where 90% of households are connected even while "dim Internet parlors that sit on practically every street corner" seems to have some associated problems. The Times quotes Korean child psychiatrist Ahn Dong-hyun as saying that "up to 30%" of South Korean children and teens (about 2.4 million) are "at risk of Internet addiction" and American psychiatrist Jerald Block as saying that "up to nine million Americans may be at risk for the disorder, which he calls pathological computer use. Only a handful of clinics in the United States specialize in treating it, he said." The article leads with the story of a 15-year-old patient at Jump Up who'd been spending 17 hours a day online. [For Dr. Block's work in the area of videogames, see "Notable fresh videogame findings."]