*2.7.2. Phase 2: Cognitive restructuring*

*2.7.1. Phase 1: Behavior modification*

190 Cognitive Behavioral Therapy and Clinical Applications

job-related functioning [53].

of CBT-IA [62].

favorite times of online.

online use.

In this phase of the CBT-IA, behavior therapy is applied to examine both computer behavior and noncomputer behavior. Computer behavior deals with actual online use, with a main purpose of abstaining from questionable applications while maintaining controlled usage of the computer for legal purposes [53]. This could be explained by the example of a university student who was addicted to Internet porn movies would need to learn to refrain from these movie Websites while still being able to use Internet for academic activities, social networking, and conducting e-mails to his contacts. Noncomputer behavior concentrates on assisting clients to promote favorable life style activities without the Internet. The activities that do not encompass the computer usage are examined and may involve activities related to social or

A previous study [60] found that Internet addicts felt a sense of displacement when online and were incapable to handle the main aspects of their lives due to increasing preoccupation with Internet usage, which affect their work (e.g., ignoring and skipping the deadlines of their work), relationship with their families (e.g., giving little time for their families), social relationships with their friends, colleagues, and community, and their normal routines. As Internet addiction progressed, addicts become expanded with their online activities such as Internet games, chatting, and gambling, which lead to ignorance of social life instead of being alone in front of the computer [61]. Time management for Internet addicts is the primary aim

It is always important to be aware of the main goal in this phase, which is modifying unhealthful computer behavior to healthful one. In the beginning of implementation of this phase, the therapist should assess the client's present use of the Internet. A daily Internet activity dairy could be adopted to evaluate client's behavior and develop a plan for treatment [53]. This dairy should include date and time of each session, event, Internet activities (e.g., mailing, chatting, Web surfing, and shopping), situations, duration, feelings that trigger excessive online usage, and outcome of the Internet session (what activities were achieved, what activities were stopped while online). The recovery success among Internet addicts could be measured through reduced online hours and abstains from any contact with problematic online applications. According the results of the daily dairy, therapist could review the duration and

It is necessary for the clients to get rid of any problematic online behavior. This could be achieved by using computer restructuring or reorganization strategy. The clients should remove bookmarks or favorite files and sites that lead to the problem online. Then, the therapist puts time management goals with the addicts and uses many methods to help them interrupt old patterns of addictive online behavior such as taking routine computer breaks, using alarm or timer as reminder to do another activity (e.g., walking through the office or garden or home, or see what family is doing in the living room) and using filtering software that could be used to block access to some online sites and can help clients to self-regulate In application of this phase of treatment, many methods are used including assessment of the type of disturbance, problem solving methods, coping techniques, modeling, support group, and self-thought monitoring [62].

The therapy classifies the maladaptive cognitions that are employed as triggers for excessive use of the Internet. For example, some addicts are suffering from distorted thoughts concerning themselves such as rumination (e.g., they are continuously thinking and concerning regarding the problems related to their Internet use) and intense self-concepts that serve their availability online (e.g., we have no value offline; however, we are other persons in online world). The Internet addicts experience distorted thoughts regarding their world, for example, "We do not like the people because nobody appreciate us" and "the Internet world is the only site where we are respected and appreciated." These extreme thoughts are distinguished by all or nothing thinking that intensifying and preserving the clients' online addiction. This could be explained by the following example: In Internet games, the addicts who carry out their goals in these games could realize the offline world as not desired, which results in psychological dependence on using the online to enhance their self-esteem. Online addicts have a cognitive bias that they are treated with respect in their virtual world, but they feel unhappiness and lack of satisfaction with real lives. These thoughts encourage them to engage in the online. Cognitive restructuring is used to breach this pattern of behavior. In this stage, the therapist puts the addict's thoughts "under the microscope," and the addict is challenged by rewriting the negative thinking related to him/her. Moreover, CBT-IA assists addicts to recognize that they use the Internet to keep away from any situation or feeling.

Cognitive restructuring will help addicts reevaluate the rationality and validity of these interpretations. For example, addict who uses Internet games to build self-esteem will begin to understand that using Internet is for the satisfaction of the unfilled needs in his or her real life. When the addicts have awareness of their patterns of mistaken thinking, they start to challenge these thoughts more independently of therapy. In this way, they will have difficulty to reason or justify their online usage and to break the cycle of connecting online usage with the best life. Through faults in addicts thinking, they feel worsted because they overestimated difficulties and lessen the potential of corrective actions.

The CBT-IA assists addicts to determine the main problems or consequences caused by Internet addiction in order to help them stay concentrated on treatment goals. In addition, the therapist asks the addict to make a list of the five main problems result from Internet addiction and a list of the five main advantages for lowering or avoiding online use in order to identify consequences. Clients' reassurance is very important because it is making their decision list broad and all comprising, and it should be honest as possible. The therapist should learn the worthy skill of clear-minded assessment of consequences for any recovery from online addiction and relapse prevention.

This phase is used to deal with denial that frequently exists among Internet addicts and to resist the defense mechanism of rationalization that clarifies excessive Internet use. Online addicts have ambivalence feelings toward treatment. They may enter the treatment sessions with mixed feelings because they are not taking responsibility for their behavior and are not certain from their desire to quit their online use. The addict considers Internet as a healthy outlet just to rationalize his behavior, "This behavior does not cause any harm to anybody else", this is not a big deal, "The Internet is not a problem in my life, it is the stress." They also lower from the hurt that causes to loved ones: "It is a device," "It is not a sexual relation outside marriage," "It is only words on the screen."

learn more effective stress management methods to assist them to relax instead of depending on the Internet in order to control job stress. The addicts are helped to find new jobs or career opportunities if they suffer from work difficulties. This thing minimizes the harmful consequences of Internet abuse and helps the recovered addicts develop new and healthy

Internet Addiction and Cognitive Behavioral Therapy http://dx.doi.org/10.5772/intechopen.71277 193

Relatively little research have been done to evaluate the efficacy and effectiveness of CBT in treatment of Internet addiction. In a previous study conducted by Orzack et al. [64] to evaluate the effectiveness of using group therapy treatment, readiness to change (RtC), cognitive behavioral therapy (CBT), and motivational interviewing (MI) interventions and to examine the impact of comorbidity on the outcomes of the treatment among 35 males suffered from problematic Internet-enabled sexual behavior (IESB) for 16 weeks. The addicts were classified into three groups: anxiety, attention deficit hyperactivity, and mood. The findings showed significant improvements in clients' quality of life and scores of depression symptoms; however, no significant improvement was reported in Internet use. Concerning comorbidity, the anxiety group reported the best response to treatment, while mood group response was positively relative and attention deficit hyperactivity

Young [53] conducted a study on 114 Internet addicts by using cognitive behavioral therapy. The outcome variables were evaluated on the third, eight, and twelve sessions and over a 6-month follow-up. The results showed that the majority of clients achieved apparent clinical improvement in managing their complaints at the end of the eight session, and the clients had ability to maintain their improvements in symptoms management at a 6-month follow-up. Online time management was reported as the highest improvement in the early times of the therapy. Social problems including restoration of non-Internet relationships and attachment in non-Internet activities were resolved upon the 12th session. Non-Internet sexual functioning was reported as the least improvement. Many clients reported keeping away from sexual chats and online pornography, but there were problems in their marital relationships. Five clients were divorced

In another study, Du et al. [65] studied the effect of a cognitive behavioral group therapy in treatment of Internet addiction. Two groups were selected randomly, in which the first group consisted of 32 clients aged between 12 and 17 years who had the school-based group CBT and the second group consisted of 24 clients who did not expose to any intervention. The clients were evaluated three times: pretreatment, immediately after treatment of eight sessions, and in the sixth month. The results showed the treatment group had improvements in time

In a recent study, Young [59] evaluated the effectiveness of the model of CBT-IA in treatment of Internet addiction. A total of 128 addicts were recruited, the Internet Addiction Test (IAT) was used to assess and classify them, and then, they received twelve sessions of CBT-IA/week. The effect of treatment was evaluated at the end the 12 weeks, 1 month,

because of inability to restore a satisfactory sexual relationship with their partners.

management skills, emotional, cognitive, and behavioral symptoms.

**2.8. Clinical applications regarding the effectiveness of CBT-IA**

coping strategies.

showed no response.

In this therapy, the addicts are faced when they conflict themselves. At the first session, they admit to have an addiction. The next session, they lower the same behavior of addiction. In this stage, the treatment assists addicts to take the responsibility of the problem. The addicts recognize that they will stick to a structured online time management plan, if they admit their addiction, which is the important focus in this stage of therapy because it remains addicts that they take a daily commitment, and if they are not ready to take this appointment for themselves, and someone else, then abstaining will be difficult to preserve.

### *2.7.3. Phase 3: Harm reduction therapy (HRT)*

During this stage, the therapist identifies and addresses the factors related to development of Internet addiction including personal, situational, social, psychological, or occupational issues [63]. The addicts suppose that they are recovered once stopping this behavior and say "We are recovered." However, there is much more to complete recovery than merely stopping the Internet. Full or complete recovery means examining the fundamental issues lead to the compelling behavior and finding solutions to these issues in a healthy way; on the contrary, relapse is probable to happen. As a part of recovery, the HRT is considered as an important method for the addict to indicate the main issues leading to the addiction [63]. It is necessary to explain that addicts begin to be dependent on the Internet because it provides an urgent and acceptable means of temporarily avoiding psychological or situational problems.

The harm reduction therapy (HRT) is used to identify the coexisting issues in the online addicts' lives. Internet becomes a fantasy world that can take them away from their problems. Through using the Internet, people recognize a safe and easily accessible way to escape. The HRT stresses on identifying and treating underlying psychiatric problems coexisting with compulsive online usage by administering, when indicated, appropriate medications. It focuses on treating dual diagnosis with depression, anxiety, or obsessive-compulsive disorder that is common among Internet addicts, as well as comorbid addiction to alcohol or drugs. Later on, 12-step recovery may be involved as part of treatment.

Harm reduction focuses on the client's strengths and capacity to change as the starting point. In this phase, the main focus of the treatment sessions is raising awareness toward the issues leading to compulsive online use. Addicts are encouraged to participate in setting up the treatment and selecting the useful goals and strategies. The addicts work to find healthy ways to deal with feelings of low self-esteem without Internet use. In addition, the addicts learn more effective stress management methods to assist them to relax instead of depending on the Internet in order to control job stress. The addicts are helped to find new jobs or career opportunities if they suffer from work difficulties. This thing minimizes the harmful consequences of Internet abuse and helps the recovered addicts develop new and healthy coping strategies.

### **2.8. Clinical applications regarding the effectiveness of CBT-IA**

addicts have ambivalence feelings toward treatment. They may enter the treatment sessions with mixed feelings because they are not taking responsibility for their behavior and are not certain from their desire to quit their online use. The addict considers Internet as a healthy outlet just to rationalize his behavior, "This behavior does not cause any harm to anybody else", this is not a big deal, "The Internet is not a problem in my life, it is the stress." They also lower from the hurt that causes to loved ones: "It is a device," "It is not a sexual relation

In this therapy, the addicts are faced when they conflict themselves. At the first session, they admit to have an addiction. The next session, they lower the same behavior of addiction. In this stage, the treatment assists addicts to take the responsibility of the problem. The addicts recognize that they will stick to a structured online time management plan, if they admit their addiction, which is the important focus in this stage of therapy because it remains addicts that they take a daily commitment, and if they are not ready to take this appointment for themselves, and someone else, then abstaining will be difficult to

During this stage, the therapist identifies and addresses the factors related to development of Internet addiction including personal, situational, social, psychological, or occupational issues [63]. The addicts suppose that they are recovered once stopping this behavior and say "We are recovered." However, there is much more to complete recovery than merely stopping the Internet. Full or complete recovery means examining the fundamental issues lead to the compelling behavior and finding solutions to these issues in a healthy way; on the contrary, relapse is probable to happen. As a part of recovery, the HRT is considered as an important method for the addict to indicate the main issues leading to the addiction [63]. It is necessary to explain that addicts begin to be dependent on the Internet because it provides an urgent and acceptable means of temporarily avoiding psychological or situational

The harm reduction therapy (HRT) is used to identify the coexisting issues in the online addicts' lives. Internet becomes a fantasy world that can take them away from their problems. Through using the Internet, people recognize a safe and easily accessible way to escape. The HRT stresses on identifying and treating underlying psychiatric problems coexisting with compulsive online usage by administering, when indicated, appropriate medications. It focuses on treating dual diagnosis with depression, anxiety, or obsessive-compulsive disorder that is common among Internet addicts, as well as comorbid addiction to alcohol or drugs.

Harm reduction focuses on the client's strengths and capacity to change as the starting point. In this phase, the main focus of the treatment sessions is raising awareness toward the issues leading to compulsive online use. Addicts are encouraged to participate in setting up the treatment and selecting the useful goals and strategies. The addicts work to find healthy ways to deal with feelings of low self-esteem without Internet use. In addition, the addicts

Later on, 12-step recovery may be involved as part of treatment.

outside marriage," "It is only words on the screen."

192 Cognitive Behavioral Therapy and Clinical Applications

*2.7.3. Phase 3: Harm reduction therapy (HRT)*

preserve.

problems.

Relatively little research have been done to evaluate the efficacy and effectiveness of CBT in treatment of Internet addiction. In a previous study conducted by Orzack et al. [64] to evaluate the effectiveness of using group therapy treatment, readiness to change (RtC), cognitive behavioral therapy (CBT), and motivational interviewing (MI) interventions and to examine the impact of comorbidity on the outcomes of the treatment among 35 males suffered from problematic Internet-enabled sexual behavior (IESB) for 16 weeks. The addicts were classified into three groups: anxiety, attention deficit hyperactivity, and mood. The findings showed significant improvements in clients' quality of life and scores of depression symptoms; however, no significant improvement was reported in Internet use. Concerning comorbidity, the anxiety group reported the best response to treatment, while mood group response was positively relative and attention deficit hyperactivity showed no response.

Young [53] conducted a study on 114 Internet addicts by using cognitive behavioral therapy. The outcome variables were evaluated on the third, eight, and twelve sessions and over a 6-month follow-up. The results showed that the majority of clients achieved apparent clinical improvement in managing their complaints at the end of the eight session, and the clients had ability to maintain their improvements in symptoms management at a 6-month follow-up. Online time management was reported as the highest improvement in the early times of the therapy. Social problems including restoration of non-Internet relationships and attachment in non-Internet activities were resolved upon the 12th session. Non-Internet sexual functioning was reported as the least improvement. Many clients reported keeping away from sexual chats and online pornography, but there were problems in their marital relationships. Five clients were divorced because of inability to restore a satisfactory sexual relationship with their partners.

In another study, Du et al. [65] studied the effect of a cognitive behavioral group therapy in treatment of Internet addiction. Two groups were selected randomly, in which the first group consisted of 32 clients aged between 12 and 17 years who had the school-based group CBT and the second group consisted of 24 clients who did not expose to any intervention. The clients were evaluated three times: pretreatment, immediately after treatment of eight sessions, and in the sixth month. The results showed the treatment group had improvements in time management skills, emotional, cognitive, and behavioral symptoms.

In a recent study, Young [59] evaluated the effectiveness of the model of CBT-IA in treatment of Internet addiction. A total of 128 addicts were recruited, the Internet Addiction Test (IAT) was used to assess and classify them, and then, they received twelve sessions of CBT-IA/week. The effect of treatment was evaluated at the end the 12 weeks, 1 month, 12 months and at 6-month posttreatment. The findings found that more than 95% of the clients had ability to manage the problem at the end of the 12 weeks, and 78% maintained recovery 6 months after treatment.

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