**2.7. Cognitive Behavioral therapy for Internet addiction (CBT-IA)**

It is also reported that negative personality characteristics including depressive thoughts, low self-esteem, poor self-perception and concept [38, 53], novelty seeking, harm avoidance, low reward dependence [38], impulsivity [36, 49], introversion, low agreeableness, and emotional instability [54], escapism and fantasy [30], could lead to the development of Internet addiction. Furthermore, the following internal characteristics were documented as risk factors: low life satisfaction [17], low well-being [54], loneliness, lack of confidence [17, 30], preference for online social interaction, negative life outcomes [47], and seeking for

Internet addiction results in experiencing physical, social, and mental or psychological problems. It has been linked to physical problems like sleep disturbance, eating problems, limited physical activity, back strain, eyestrain, and others [52]. Research literature has been demonstrated that Internet addiction leads to a poor health condition, excessive daytime sleepiness, insomnia, nightmares, difficulty in falling asleep and night awakenings [2], loss of energy, physiological dysfunction, weakened immunity [17], overweight and obesity, and impaired

The Internet addicts transfer their social lives into the Internet world. Internet addiction leads to many social issues such as disturbing family, social, and workplace relations, where it isolates the persons from family and society and keeping them away from social interactions [27]. It has a negative effect on interaction with peers and friends, family life, academic life,

It is important to understand that Internet addiction may lead to negative effects on psychological development for population. The worst effects are Internet anxiety [38, 46], depression [30, 32, 33, 36, 51], suicidal ideation [51], social phobia and phobic anxiety [41], schizophrenia, obsessive-compulsive disorder [30], antisocial/aggressive behaviors [49], self-injurious behavior [56], harmful alcohol use [46], and sleeping disorders [31]. In a Chinese study conducted among school students, the results indicated that the scores for comorbid disease and impulsivity were higher among students experienced Internet

Treatment for Internet addiction is similar to treating any other types of addiction. It involves

• **Cognitive behavioral therapy (CBT)** is a short-term and problem-focused type of behavioral treatment. It focuses on helping clients consider the relationship between beliefs, thoughts, and feelings and following behavior patterns and actions. During CBT, clients learn that their perceptions influence directly on responses to specific situations. In particular, a client's thought process guides his or her behaviors and actions. Cognitive

cognitive behavioral therapy, interpersonal psychotherapy, and support groups.

enjoyment and entertainment [49].

188 Cognitive Behavioral Therapy and Clinical Applications

vision [55].

and social life [41].

addiction [52].

**2.6. Treatment for Internet addiction**

**2.5. Negative consequences of Internet addiction**

This is the first model of its kind and the most effective type of therapy for Internet addiction that is focusing on cognitive behavioral therapy (CBT). Researchers have documented that using cognitive behavioral therapy (CBT) is an effective treatment for Internet addiction [53]. The CBT in general helps addicts to realize addictive feelings and actions, while learning new coping skills and methods to prevent a relapse. The CBT usually takes 3 months of treatment or approximately 12 weekly sessions. The focus of this therapy is to assess the client's patterns of use and then develop new schedule to change the past formed patterns. External influences such as activities that demand the addict to leave Internet could be applied. There are also treatment programs that help the client in identifying goals about the time needed for using the Internet.

The CBT-IA model is a comprehensive approach which can be divided into phases, including (1) behavior modification, (2) cognitive restructuring, and (3) harm reduction therapy (HRT). The first phase or the early stage of therapy is behavior modification that is focusing on specific behaviors and situations where the impulse control disorder causes the significant difficulty and is used to control compulsive Internet use and reduce the time spend online by addict. The second phase is a cognitive restructuring that is applied to identify, challenge, and adjust cognitive disruptions and negative beliefs that cause a compulsive usage of Internet and effect on this behavior of addiction [53]. The third phase is harm reduction therapy (HRT) that is a new and untested therapy, which is used for continuation of recovery and prevention of relapse. The HRT is used to recognize and cure psychiatric problems related to Internet addiction and treat social problems in relationships with families, peers, and friends. We will discuss each in turn.

#### *2.7.1. Phase 1: Behavior modification*

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 job-related functioning [53].

*2.7.2. Phase 2: Cognitive restructuring*

and self-thought monitoring [62].

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,

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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 recog-

nize that they use the Internet to keep away from any situation or feeling.

difficulties and lessen the potential of corrective actions.

addiction and relapse prevention.

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

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

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

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 of CBT-IA [62].

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 favorite times of online.

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 online use.
