IN-Patient Treatment for Internet Addiction?

Last week, Mashable.com reported, "First U. S. Rehab Center for Internet Addiction Opens Its Doors." In the story, the case of a 19-year-old male who "could not remove himself from World of Warcraft," a popular online multi-player war game, was used to segue to an essay on inpatient treatment for Internet addiction. This prompted a rather provocative question from a reader: "I'm not sure I buy it. I spent two years in grad school reading books 16 hours a day and not going out in the 'real world.' Should I have ponied up $15k for some 'education' rehab?"

The “treatment” provided the 19-year-old is treatment for what is referred to as a “process addiction,” something akin to gambling or sex “addiction.” As with any addiction, a diagnosis can only be made when several diagnostic criteria have been met…and as the article reports, these have yet to be quantified in the Diagnostic and Statistical Manual of Mental Diseases for Internet addiction. Generally, the “non-scientific” diagnostic criteria for addiction include: (1) compulsive behavior that is (2) chronic and (3) continues in spite of known associated negative consequences, and (4) attempts at changing the behavior result in relapse (meaning a return to the compulsive behavior). With gambling and sexual addictions, which not only meet these criteria, but result in demonstrable chemical changes in the brain, a key element in discerning why process addictions are considered by many to be true “addictions" even though the individual does not consume a psychoactive substance (see "Gamblers's Brains") is met.

Clearly the jury is still out on this with many behaviorally oriented practitioners seeing process addiction as being more the result of “cognition and/or learned behavior” than “organic and/or physical processes." That said, there are demonstrable chemical changes (able to be documented with PET scans) that occur when addicted individuals are presented non-substance related stimuli. This means that the reward pathway in the brain is activated by behavior in a similar fashion to when psychoactive substances--or anticipation of their use--are administered (see Drugs Alter the Brain's Reward Pathway). In the case of the experienced user, it is the anticipation of the chemical that results in these chemical changes in the brain; in the gambler—and perhaps the video gamer cited in the article—it is the behavior that results in the stimulation of the chemical rewards that translate into “addiction,” i.e., “compulsion,” “chronicity,” and “relapse.”

Although one may have spent 16-hours a day reading and studying when in grad schools, the reasons for doing so were different than those of the 19-year old “addicted” to War Craft. In addition, once an individual completed his or her degree—the reason those hours were spent studying—the “studying behavior" changed without negative consequences, i.e., “withdrawal.” True, the student may have learned to enjoy this studying behavior/pattern and may continue that behavior to this day, but likely in a significantly different way, not to mention that the change was not marked by repeated failures to realize the change. In short there is a difference between engaging in a behavior because you “cannot not” stop and continuing a behavior because it is a means to a desired end. Eating is a good example of this.

Compulsive eaters, a.k.a., "food addicts," cannot not eat—or cannot not binge and purge, etc. Their treatment does not have the same goal, however, as treatment for a cocaine or alcohol dependency—abstinence, although some still argue that abstinence is not necessary as a condition of change when treating substance use disorders, but this is a topic for another discussion. The objective of treatment for this individual is to establish a new and different “relationship with food,” a constructive rather than destructive relationship. Whereas one can live without alcohol or heroin, one cannot live without food, hence, the objective of treatment for the two similar disorders is different. What is not clear in the cited Mashable article is if the objective of the treatment is abstinence from the Internet or learning to use it constructively; I suspect that the objective is similar to that in treating gambling…abstinence.

In short, I am not sure, yet, where I stand on the need for in-patient treatment or 12-step groups for Internet Addicted individuals. I do embrace the argument that “treatment” in the form of counseling and behaviorally oriented skills training can be useful, but then I believe that most people can benefit from “counseling’ where the focus is either overcoming obstacles that preclude success in a particular area of one’s life and/or learning new skills that allow one to move towards realizing a stated goal.

I suspect that as we learn more about dependence (a.k.a. addiction) we will learn that there are behavioral stimuli that initiate the same physiological and neurological responses seen in individuals addicted to psychoactive substances. I have watched the addictions field progress far in the last 35 years and it is likely that we have but "merely opened the book" on what there is to be known. There is compelling information to argue that "Internet addiction" is a real disorder, but documenting that--and more importantly--identifying the best course of treatment remains to be seen.

What do you think? Leave a comment.

Keeping Up with The Field

My grandfather used to say, “Wisdom is the gift received when recognizing the limits of one’s knowledge.” The more aware I became of the limits of my knowledge related to addiction and AOD issues in general, the more I sought out direct and indirect sources of that information. When first entering the field of addiction treatment in the early 70s I invested time in several activities that continue to pay dividends to this day. This entry is intended to share a few of this "FYI."

(1)Attend open 12-step meetings. It is at such meetings that one can learn about addiction and recovery (and the “early years,” perhaps before addiction, which can be useful when doing counseling with collegians).

(2)Training opportunities where funding may very well support doing so, but also look into “free” workshops and seminars that were available in the community. In the 21st century, this is somewhat easier in that there are online seminars and discussion groups as well as workshops run by different treatment programs and such. NOTE: Addiction treatment programs or hospitals in your area sponsor free monthly free workshops. NOTE: Not only are such workshops useful for what can be learned, but also (and perhaps more importantly) for who you can meet professionally.

(3) Read as much as you can on the topic(s) of your choice. Although no one can ever read “everything” that is available to be read, here are some tricks you can try to increase the amount of information you can expose yourself to. For example, you can do a key word search for journal articles that have several keywords that related to a topic of interest. For example, you can search “collegiate drinking,” “prevention” and “strategies.” You can do this at http://scholar.google.com (or just plain google.com) or one of the online databases, for example, project CORK at Dartmouth (http://www.projectcork.org/) or NIAAA’s ETOH database (see http://etoh.niaaa.nih.gov/). If you search at a database and get “X” hits, read the abstracts for the more interesting ones or just the first 5 or 10 or however many. These abstracts give you a sense of what is happening as well as what is being published.

For those abstracts you find interesting (or for anything else you may find online that is interesting and in print form) you can download the .doc or .pdf (or “.whatever” text file) and then convert it to a mp3 audio file at http://zamzar.com and then listen to it on you mp3 player when commuting or exercising, etc. NOTE: It takes a few minutes to get used to listening to the computerized “text-to-speech” syntax, but once you catch on, it is an easy way to “read" more stuff related to a topic of interest.

(4) As they say in AA, look around for someone who has what you want and then get to know that person. In AA it is called “getting a sponsor”; in professional development it is called finding a mentor(s). Ask that person if you can meet and chat. Invite the person to coffee. Ask if you can exchange emails. In short, do what you can to learn from that individual(s). You may need to invest some time in traveling to that person’s office or suggested location, but once a month or however often you do this can be a small investment for what you get in return…and you are not restricted to one mentor at a time 

(5) Join several listserv discussion groups and/or sign up for daily or weekly email reports on “what’s what” in your chose field. For example, you can get daily news from http://www.JoinTogether.org or “drug and alcohol findings” at http://findings.org.uk/ In short, there are likely “countless” places where you can have folks send you snippets of information on a regular basis and you read what you have time/interest to read. Add to this the countless blogs and pod
casts that are available and you have more than enough to keep you busy with your “knowledge quest” for years to come

If you have additional suggestions,please leave a comment.

Robert

There is an interesting article in today's Washington Post. The article, entitled, "It's Time to Legalize Drugs," by Peter Moskos and Stanford "Neill" Franklin is representative of a growing public opinion regarding drugs and more particularly, an opinion on our historically moralistic public policy on addressing their use. Although I am an advocate of changes in this policy, I am not sure the views expressed in the Post article are in our best interest as a country in the long run. Allow me to first comment on the positive points the authors make...there are two:

1. If drugs were legal then drugs could be prepared like any other commodity. This would move production out of the back alley and place it under the scrutiny of some regulatory body that could ensure that what is sold in Philly is the same as what is sold in DC as in LA, etc. In short, there is something to be said for regulating production from a harm reduction point of view...less harm to the individual who consumes the drug and less harm (most likely in the form of financial savings) to the public when it does not have to pay for the consequences of consuming “bad” drugs.

2. There is a lot of money to be saved and made by legalizing drugs. Regarding savings, the billions of dollars are no longer spent on interdiction and other law enforcement efforts to stop manufacture and distribution, to prosecute offenders, to incarcerate offenders, etc. Regarding earning, the state and federal taxes to be collected. Ironically, most drugs of abuse could be manufactured inexpensively and then taxed in an outrageous fashion and still be no more expensive to the consumer than they are now.

As attractive as these two “benefits” of legalization may be, they do not, however, off-set the potential consequences. The biggest “drug problems” we have in this country—and likely this is true around the world—is with those drugs that are already legal...alcohol (ethanol) and tobacco (nicotine). These substances are regulated and taxed yet they are together many times more costly to us as a nation than all illicit drug use combined. This is to suggest that making substances “legal” is not to redeem the country or any of its residents from the consequences associated with the use of the now legal drugs. Add to this that some of the more popular illicit drugs of abuse, namely prescription drugs taken without a prescription, are already legal and this just adds to the argument that legalization is not, in and of itself, a solution to "the drug problem."

I liken legalization of drugs as a solution to building more roads to solve the traffic problem. There may be an immediate beneficial result from the effort, but as driving becomes easier, more individuals will choose to drive and this leads to more vehicles on the road, which results eventually in a return of the original traffic problem. Legalization may appear to be a fix, but it would be a band aid on a major, hemorrhaging wound, addiction and other substance use disorders. True, marijuana would probably result in far more people “using” the substance than “abusing,” it, something on a par with alcohol, but consider that 10% of drinkers consume 50% of all alcohol consumed and you can begin to see how even small percentages of “problem users” can result in significant problems for individuals, families, and the society as a whole.

I believe a better solution is something akin to what the Netherlands did 30 years ago and Portugal, Mexico, British Columbia, and other countries are experimenting with today...decriminalization. True, this does not do much to solve the problem of “quality control” problems in the production of drugs—and this is no small problem as regulating production with something like the FDA is probably “the” strongest argument for legalization. What decriminalization does do, however, is it allows us to continue to address substance use as a public health problem where addressing the “agent” (the drugs), “host” (individual who chooses to use the drugs), and “environment” (where the drugs are used, etc.) becomes the focus and prevention of and intervention with use, not interdiction in “the war on drugs,” is the issue of primacy.

When interdiction ceases to be the predominant response to substance use disorders, prevention and treatment can take over that position. When the demand drops then the consequences associated with consumption—especially clandestine and surreptitious consumption—will likely be reduced. Just as we do not prosecute and incarcerate those who consume “trans fats” or “empty calorie” processed foods, neither should we prosecute individuals with substance use disorders.

Drugs, that is, substances with psychoactive properties have been around longer than have we humans who at times seem preoccupied with consuming them. This means that drugs are neither good nor bad, they “just are.” It is the way these drugs are used that determines if they are problematic of not, that is, “a social problem,” and as with all social problems, they are a social construction. This means that a social issue only becomes a problem when a majority of those in power in the society in which the social issue is occurring deem the issue to be problematic. For example, most people do not argue that “child abuse” or “driving while intoxicated” are “social problems.” Interestingly, though, prior to the 1960’s you did not hear about “child abuse” and prior to the 1980 you did not hear much about “drinking and driving.” This does not mean that these issues did not exist, they just were not deemed problematic by the society in which they occurred and were therefore not denoted as “social problems.”

Take “abortion” or “smoking marijuana” on the other hand and there is great debate as to whether or not either or both of these is a “social problem” because there is no consensus on either issue. Consequently, until and unless a majority of individuals in power clearly decide one way or the other, the debate will continue. Probably the clearest example of this is the slow but inexorable growth of the temperance movement in the 19th century into a movement that transformed “drunkenness” from the social problem to “alcohol itself” as the social problem and resulted in the passage of the 18th amendment in 1920. For 13 years, “alcohol” was a social problem...just as “drugs” have been since the Harrison Act was passed in the early part of the 20th century—but even that had an interesting twist in that it was not concern about the use of drugs, but racism that resulted in the passage of early drug laws...certain ethic groups tended to use certain drugs so in an effort to “get rid of the racial problem,” their drugs of choice were made illegal in order to legitimize persecution...but this is another story (see “Hooked: Illegal Drugs and How They Became That Way,” available on Youtube).

In any event, I “hear” the argument of the authors of the Post article and I “feel” their frustration, I just do not “buy” their reasoning for legalizing drugs. One thing is certain, however, and that is the old “war on drugs” approach to dealing with psychoactive substances is going to go the way of the dinosaur...its just a question if that will be with a cataclysmic event that results in mass extinction of something more “evolutionary.”

What do you think?

The following is an OP-ED piece a colleague and I have written for a local Philly newspaper...I share it here FYI

Back to the Future: What’s New in Response to College Drinking
By Robert J. Chapman, PhD & Stephen F. Gambescia, PhD
Drexel University—Philadelphia, PA
College of Nursing & Health Professions

With the approach of Labor Day and its symbolic close of summer comes another annual event that hearkens the change of seasons: Back to the classroom. In colleges & universities across the country administrators are acutely aware of the perennial issue of student drinking, given its potentially adverse academic and public health consequences, not to mention being in the midst of our current economic recession, the fiscal impact—retaining students through graduation naturally makes for sound fiscal policy.

Alcohol and collegiate life have been social contemporaries since Thomas Jefferson noticed its affects on good student form at the University of Virginia and butlers distributed wine and beer to students at Yale and Harvard, which were easily dispensed from the “Buttery,” adjacent to the Commons and an integral part of colonial collegiate life. But the convivial drinking of collegians in centuries past has been replaced by the ubiquitous consumption of contemporary students, approximately 25% of which are described as “frequent” (2 or more times in a 2-week period) “binge” drinkers (having 5 or more standard drinks in an outing, 4 or more for women).
So pervasive is collegiate drinking that colleges have attempted to control consumption. One particular approach that has been effective is called, “environmental management.” Included are five strategies:

1. Offer alcohol-free social, extracurricular, and public service options
2. Create a health-promoting normative environment
3. Restrict the marketing and promotion of alcoholic beverages both on and off
campus
4. Limit alcohol availability
5. Increase enforcement of laws and policies

In short, these steps to influence the campus environment have resulted in changes in collegiate drinking; most good, but some give pause for reflection. Although campus drinking has been reduced, “frequent binge drinkers” have tended to move off-campus to avoid increased enforcement of alcohol policies. This shift increases certain other high-risk and dangerous student practices; namely, drinking and driving as well as drinking in unsupervised and clandestine locations where excessive consumption is encouraged and alcohol poisoning is not monitored. Both of these consequences may serve to alienate residents of the community in which such drinking occurs thus straining any historic “town-gown” tensions.

As college personnel have become aware of this shift in student drinking behavior, they have changed their strategies. Most effective in encouraging a proactive response is the use of campus-community coalitions. Such partnerships of administrative and student groups “on-campus” with residents, businesses, law enforcement, and public health groups “off-campus” have resulted in significant change in curbing student off-campus drinking – see http://tinyurl.com/qsdz62.

In addition to such coalitions, campus officials that hold students responsible for their behavior off-campus and subject them to the same consequences as if the drinking was done on-campus often direct these students to participate in brief motivational screening – see http://tinyurl.com/lohw6p. Other strategies are being piloted to address these issues, but like a medication that accomplishes its primary objective but necessitating a second prescription to assuage side effects, environmental management strategies have contributed significantly to affecting collegiate drinking.
With the return of students and the adverse consequences of drinking done by some of their number, new and innovative strategies have been implemented by colleges and universities to act on rather than react to this perennial vestige of collegiate life. Although alcohol and its consumption will remain regular parts of contemporary campus life, these inventive strategies will likely result in changed student behavior.

Looking at Collegiate Drinking: Part II

Deconstructing Collegiate Drinking

If what alcohol and drinking mean as icons of contemporary collegiate life are important, then such meanings likely impact the choices students make regarding drinking. And if we can understand the process by which these meanings are ascribed, then we will likely be able to move one step closer to impacting collegiate drinking.

I suspect that the importance of alcohol in collegiate life is such that it will never cease or be controlled to the extent that only those of legal age will consume and then only in accordance with medical guidelines recommended by experts—no more than 2 standard drinks per day for males, 1 for females. That said, I do believe that collegiate drinking can be influenced and in a way that sees the percentage of students that choose to drink reduced and the frequency and quantity of those who do imbibe reduced as well.

There will always be those who experience a problem with alcohol and find themselves drinking because they “cannot not drink,” a.k.a. alcohol dependence, but such drinking by college students is limited—although some (many?) may progress to “alcoholism” propelled by their collegiate experience. The number of problems, however, associated with collegiate drinking—what I call, “untoward consequences"—can be reduced below the apparently intractable numbers that have been reported consistently for years. Ironically, this will not be because of more clever policies regarding alcohol. Likewise, changes will not result from innovative programs alone or smart and witty publicity campaigns. Rather, change will come as students move through the process by which they re-ascribe meaning to alcohol and drinking that affects the choices they make regarding the use of the drug and the circumstances that warrant that use.

There is the old adage we are so familiar with as to have made it a trite cliché—“You can lead a horse to water, but you cannot make it drink.” Although this may be true, you can salt the oats. If I shift my focus from trying to “make students” do the right thing and, instead, shift that focus to affecting the reasoning they employ that results in choices to “do the wrong thing,” students may well move in the direction of change of their own volition. We know this will happen because it already has been documented in the “maturing out” process. And whether this process is learning the “cause and effect” relationship between high-risk behavior and untoward consequences or simply the result of the natural developmental as students age from late adolescence to early adulthood during the span of a traditional collegiate career is all but irrelevant. What is pertinent is that students change and they do so of their own volition. As Sandra Anise Barnes, the poet, wrote, “It is so hard when I have to, and easy when I want to.”

The challenge for those concerned about collegiate drinking is not to “reinvent the wheel” but to keep from reinventing the flat tire. We may already have the answer to reducing the unacceptable number of untoward consequences associated with drinking…we see this as students progress through the aging-out process. The challenge is to hasten this process so as to close the window of opportunity for those untoward consequences to occur.

If we study the process by which students change the meaning they ascribe to alcohol and drinking we can artificially hasten this process, and in so doing, reduce the untoward consequences. This will not necessarily reduce the number of students who choose to drink, but it is likely to affect the number who choose to drink on a given occasion and, more importantly, the way they drink.

If we can resist the temptation to use public policy exclusively as the means by which we “solve the collegiate drinking problem” and instead focus on altering the meaning students place on the drug and its consumption, it is entirely likely that students will fix “the problem” themselves.

In conclusion, we have come a long way. Environmental management strategies and programs like social norms marketing, Brief Alcohol Screening and Intervention for College Students (BASICS), Screening/Brief Intervention/Referral to Treatment (SBIRT), have done much to address high-risk and dangerous collegiate drinking. But such external programs and approaches that serve to “do something to” students are not enough to change a culture. For the culture of campus drinking to change, students must come to a point where the meaning they ascribe to alcohol and drinking change. Then and only then will the culture on American college campuses change. As in psychotherapy, effective therapists know that individual change is an “inside job.”

To read more on this topic in some detail look at When They Drink: Deconstructing Collegiate Drinking (http://www.community.rowancas.org/node/21) and When They Drink: Is Collegiate Drinking the Problem We Think It Is? (http://www.rowan.edu/cas/resources/documents/CollegiateDrinking.doc.doc)

Comments welcome at chapman.phd@gmail.com