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CYBERPSYCHOLOGY & BEHAVIOR Volume 8, Number 1, 2005 © Mary Ann Liebert, Inc.
Internet Addiction: A Review of Current Assessment Techniques and Potential Assessment Questions KEITH W. BEARD, Psy.D.
ABSTRACT The concept of Internet addiction has been proposed as an explanation for uncontrollable and damaging use of the Internet. Symptoms of excessive Internet use have been compared to the criteria used to diagnose other addictions such as pathological gambling. Although criteria to diagnose this problem have been proposed, methods of assessing excessive Internet use are limited. A structured interview based on the criteria proposed by Beard and Wolf is proposed to aid in the assessment of “Internet addiction.” This, in turn, could aid in the diagnosis and intervention of a client who enters treatment reporting difficulties with excessive Internet use.
INTRODUCTION
lished articles contain information that has not been empirically researched.
T
HE WORLD continues to advance with new technologies.1 People are no longer confined by geographic boundaries because of inventions such as the television, fax machines, telephones, pagers, and computers. While many have focused on the incredible benefits that result from new technology, there are also some disadvantages. The Internet has been blamed for decreased family time, strains upon relationships, decreased productivity in employment settings, perpetuation of false information, and the development or exacerbation of psychological problems.2–10 The purpose of this paper is to clarify current information on the assessment of what is commonly referred to as “Internet addiction.” First, there will be a review of some unique characteristics of the Internet. Then, a model that can be used to conceptualize problematic Internet use will be briefly described. Finally, some areas to address when assessing for Internet addiction and other considerations will be discussed. At the outset, it needs to be made clear that the literature on Internet addiction is quite limited. Although more research is being conducted on the topic, many of the pub-
Unique characteristics of the Internet Certain qualities of this technology have allowed a unique Internet culture to develop. The Internet culture has its own set of language, values, standards, signs, and artifacts.9,11–15 Understanding this culture may help to better assess why the Internet is used in a person’s life and how to best intervene. A main attraction of the Internet is the ability of a person to remain anonymous.9–11,15–18 With this anonymity, unlike face-to-face communication, demographics have to be announced in order to be known.11 An Internet user can take on different personas when on-line.1,9,10,14,15 The user may create different profiles with information about himself or herself. Young9,10,15 found that some users chose identities that were an ideal self, which represented the opposite of what the person is in real life, identities that fulfilled unmet needs, or identities that represented an emotion or trait that may be repressed. Internet users often feel safe to take more emotional risks, be flirtatious, give positive and nega-
Psychology Department, Marshall University, Huntington, West Virginia.
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tive feedback to each other, and to express opinions on-line that they are unable to express to others in the real world.3,9,10,14,15,19,20 It is not unusual for two Internet users to quickly begin asking personal questions upon first meeting.1,9,14,15,20 King20 and Young9,10,15 believe that these emotional risks create a need to continue these bonds and receive the support that the user is lacking in the real world. However, support can end quickly and easily by no longer corresponding to the person. As a result, there is an illusion of companionship without the demands often placed on friendships. Finally, Young9,10,15 explained that the Internet environment allows for just about any virtual experience. A person can use applications such as MultiUser Dungeons and Dragons (MUDS) or go to areas on-line and engage in sexual fantasy. The person could also create a surrogate community by going into a chatroom and pretending to interact with others or objects in the fabricated cyberenvironment.11,14 Young15 states that, once these unconscious feelings, drives, and experiences are brought to the conscious mind, it becomes difficult for some users to suppress them again. Internet users may begin to desire these unique aspects of the Internet more and more. As a result, Internet users may begin to blur their distinction between their own personality and reality, and their on-line persona and virtual environment.
PROBLEMATIC USE OF THE INTERNET The following section explores characteristics of problematic Internet use. This term is broadly defined as use of the Internet that creates psychological, social, school, and/or work difficulties in a person’s life. Characteristics of problematic Internet use Problematic Internet use can be found in any age, social, educational, and economic range.10 In the past, those who are Internet addicted were stereotyped as predominantly young, introverted, and computer-oriented males.9,21,22 While this stereotype may have previously been true, the availability of computers and easy access to the Internet is quickly challenging this notion.23 For example, Young10 reported that 61% of her respondents were women. While she concedes that the apparent increase in women users could be the result of women being more likely to participate in research studies, the increase in women using computers could also be a result of increased availability of the Internet.
Subjects who met Young’s proposed criteria7–10 for problematic Internet use described their personalities as bold, outgoing, open-minded, and assertive. At the same time, many of the Internet users reported being depressed and lonely, and having low self-esteem and anxiety. Other common personality characteristics included having pride in their intellect and the use of the defense mechanism called “intellectualization.”4,11,23 Twenty-five percent of those who completed Young’s survey8–10,15 on the Internet reported becoming addicted to the Internet within the first 6 months on-line. Young went on to report that 58% of the respondents met her criteria for Internet addiction within 1 year. This could mean that new users are more vulnerable to pathological Internet use. Most felt intimidated by the computer initially but began to feel a sense of competency and exhilaration from mastering the technology and learning to navigate the applications quickly.1,4,8–10,15,24 Applications that allow for two-way communication—such as character games, news groups, and email—are the applications most likely to be abused.8,10,15,17,25 The survey administered by Young8,10,15 also found that her addicted respondents used the Internet an average of 38 h per week. Respondents admitted to trying to cut down on their Internet use and failing despite significant problems that their Internet use was causing. Scherer21 has found that Internet-addicted college students use the Internet an average of 8.1 h per week and engage in email, the WWW, and library services. They were also more likely to use the Internet for leisure than nonaddicted students. In general, teens have been found to use the Internet more hours than adults.24 The concept of Internet addiction and the material aspects of it have been compared to other nonchemical addictions such as sexual addiction, eating disorders, compulsive gambling, excessive television viewing, compulsive buying, and excessive exercise.1,6,8–10,15,16,21,26–34 Like other addictions, Internet user’s desire and preoccupation builds again over time. Finally, relapse prevention techniques that have been used with other chemical and non-chemical addictions are believed to be effective with Internet addiction behaviors. Further research is needed in order to understand all of the similarities that Internet addiction has with other impulse control disorders and non-chemical addictions. Griffiths17 and Young7,10,22 claim that Internet addiction, like other addictions, involves the person engaging in the activity excessively. Various states of arousal, pain, and stress can influence Internet use, resulting in an uncontrollable desire and preoccupation with the Internet. Therefore, a sense
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of relief from the built-up tension can occur once the Internet is used. A proposed model to conceptualize problematic Internet use The following is a model that I have proposed for conceptualizing problematic Internet use. It is based on the biopsychosocial model of addiction, integrating biochemical, genetic, psychological, familial, environmental, and cultural dynamics. The biological view recognizes that biological or neurochemical changes may occur in a person engaging in an addictive behavior. For example, there may be a combination of genes that make a person prone to developing addictive behaviors.35 Another possibility is that the user has an insufficient amount of serotonin or dopamine, which could contribute to addictive behaviors.36,37 Therefore, engaging in excessive Internet use may alter physiological states and help the body maintain homeostasis or create a sense of euphoria. Pharmacology can be used to aid a person with this aspect of his or her addiction. A psychological view recognizes that classical conditioning may play a part in initiating, maintaining, and changing behavior of those addicted to the Internet. For example, physiological arousal may be conditioned to occur to external cues such as seeing the computer, turning on the computer, or waiting for Internet information to be downloaded. Associations between internal states— such as excitement, stimulation, pleasure, hope, and surprise—can then be made, resulting in the user becoming psychologically dependent on the feelings and experiences provided from using the computer.7,10,17,22,38 Operant conditioning is another psychological aspect that may play a part in the initiating, maintaining, and changing of behavior of those addicted to the Internet. In terms of addictive behavior, operant conditioning typically focuses on the reinforcing aspects, such as thoughts, feelings, and behaviors, of a substance or task. Using the Internet may be encouraged by a variety of reinforcing factors such as gaining and accessing information quickly and maintaining contact with people. When problems result from excessive Internet use, the person will more readily engage in Internet use to receive some relief from these problems. Additionally, engaging in an activity such as checking email may follow a variable ratio schedule of reinforcement. Similar to a slot machine, the user gets a “pay off” with the varying number of times the email is checked. For example, the user may check his or her email three times and be reinforced with an email, and then
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check it seven times before she or he is reinforced again with an email. A social view recognizes that there may be familial, social, and cultural dynamics that prompt excessive Internet use. For example, the person may use the Internet to escape family conflict. However, the need to use the Internet can create significant distress or impairment in social, occupational, and other important areas of functioning, resulting in continued addictive behavior as an attempt to mask these problems.1,6,10,15,19,21,23,24,31 Modeling could play a role in problematic Internet use. Users can witness those around them engaging in Internet use as a way to meet others, be entertained, and solve problems. As a result, the Internet may be seen as a primary resource and method of meeting numerous needs. Furthermore, the environment in which the Internet is being used could also increase the potential for pathological use. Using the Internet in the comfort of one’s home can increase the chances that the person will not want to leave this environment. The greater the availability of the Internet, the increased chance that people will engage in Internet activities. According to some researchers,21,24 this could explain why college students, who receive unlimited and free Internet access through their school, are at greater risk for developing pathological Internet use. Another possible social aspect is that the person lacks certain social skills that would enable him or her to fulfill this need for affiliation in places other than the computer. Likewise, there may be expectations and peer pressure from friends for the Internet user to engage in various on-line activities. Finally, cultural factors such as the push to be a “technologically advanced society” or the necessity to use the Internet at work could encourage Internet use to a point that is detrimental to the person.
ASSESSMENT Assessment may be done through the administration and integration of various assessment instruments. Additionally, a clinical interview may also be an effective way to determine if a person is engaging in problematic Internet use. Clinical interviews should always be done and can be used in conjunction with a standardized assessment instrument or in isolation. Standardized tests specifically assessing excessive Internet use There are a limited number of standardized tests that have been developed for assessing problematic
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Internet use. Young7–9,15 developed one of the first questionnaires that assessed Internet addiction. She initially developed a short eight-item questionnaire that was a modification of the criteria for compulsive gambling. The significant findings from this questionnaire prompted the development of a larger and more comprehensive instrument called the “Internet Addiction Test,” consisting of 20 questions. The questionnaire was developed to help respondents in three ways. First, for those who already identify as being an Internet addict, the questionnaire helps to assess in what areas the problem has impacted the person’s life. Second, for those who are not sure if they are Internet addicted, the questionnaire will help them determine whether they meet Young’s criteria10 for Internet addiction and assess the impact it has had on their daily living. Finally, Young’s questionnaire was developed to help those who believe that they know someone who is pathologically using the Internet by allowing that person to rate the Internet user or to give this questionnaire to the user. Since the development of the Internet Addiction Test, other assessment instruments have been developed to assess for Internet addiction. Caplan39 described the Generalized Problematic Internet Use Scale (GPIUS). Results from a preliminary study indicate that the GPIUS is reliable and valid. A factor analysis identified seven sub-dimensions, including mood alteration, perceived social benefits available online, negative outcomes associated with Internet use, compulsive Internet use, excessive amounts of time spent online, withdrawal symptoms when away from the Internet, and perceived social control available online. These subscales were correlated with psychosocial health variables including: depression, loneliness, shyness, and self-esteem. Davis25 described the use of the Online Cognition Scale (OCS) and a study that focused on procrastination, impulsivity, and social rejection as key elements of problematic Internet use. By using this instrument and other measures of procrastination, rejection, sensitivity, loneliness, depression, and impulsivity, it was concluded that problematic Internet use consists of four dimensions: diminished impulse control, loneliness/depression, social comfort, and distraction. Davis has recommended this instrument for clinical assessment of problematic Internet use and as an employment screening instrument. Although the findings from these preliminary studies are promising, additional research is needed. The need for more research is based on
BEARD
some criticisms regarding these assessment instruments. Additional research would help solidify the reliability and validity of these measures. Furthermore, these instruments are based on different theoretical underpinnings and do not agree on the underlying dimensions that make up problematic Internet use. Another criticism is that some items do not relate to addiction. There are also general concerns related to using a self-report method of assessing for Internet addiction. Test takers may not answer honestly. Questions may be answered in such a manner that will present the test taker in a certain way. No “lie” scale has been developed to account consistently for this type of responding. Another general concern with self-report measures is that participants may not understand various questions or misinterpret the various test items. Additionally, there is also a problem with the participant pool. Participants were obtained from web sites or undergraduate courses leaving the potential for a selection bias to occur and no adequate control group to use as a comparison. Furthermore, there could be slight nuances in the administration and order of various tests along with factors on a web page that may influence how people responded as well as the number of valid responses obtained. Although some of the studies looked at various applications on the Internet, these instruments do not take into account all of the different types of applications that make up the Internet. This could include things such as email, games, pornography, and chatrooms. As a result, an inaccurate assessment of the types and extent of abuse that could be occurring is obtained since a person may show addictive behaviors toward one application, but not others. A few other instruments try to assess problematic Internet use, but they are criticized even more than the instruments already described. One test is the Internet-Related Addictive Behavior Inventory (IRABI), which consists of 32 true-false questions. King20 reported on other Internet addiction questionnaires found on the Internet such as the McSurvey by Steve Thompson. Questions address things such as the level of the respondents’ physical distress, whether the Internet had a negative impact on their lives, and if they perceived a real life deficit in personal relationships. The researcher goes on to discuss a 6–7-point Likert scale questionnaire developed by Egger. Questions included items related to the urge to use the Internet when off-line, anticipation of his or her next Internet usage, feeling guilty over his or her Internet usage, and lying to friends about how much time they spent on-line.
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Clinical interview Since there are numerous limitations to the current standardized instruments that assess for Internet addiction, I recommend, for now, the clinical interview be the primary method of assessment. Assessing for Internet addiction needs to include an understanding of the presenting problem. This should consist of general information that helps to define the parameters of the problematic behavior, the impact the behavior has on the client’s life, and the level of motivation to change.32 It is necessary to evaluate the level of motivation that the Internet addict has to change. Several investigators32,40–42 have described assessing the motivation to change within six stages: Precontemplation, Contemplation, Decision, Action, Maintenance, and Relapse. A client may be in the Precontemplation stage of motivation, when he or she denies the problem and is resistant to treatment. During the Contemplation stage, the client begins to explore the pros and cons of partaking in addictive behavior. The Determination stage occurs when the client gains self-efficacy and is determined to make some change. The Actions stage occurs when the client implements plans for change. The Maintenance stage is a continuation of the change process and achievement of personal goals. Finally, there is the Relapse stage, which is an expected part of the change process. The goal is to reduce problems that occur with relapse and help the client move back into the Contemplation, Determination, and Action stages. While assessing the stage of motivation, a general history on the client can be obtained. In keeping with the biopsychosocial model and the diagnostic criteria proposed by Beard and Wolf,16 information on biological factors, psychological factors, and social factors, should be reviewed to help the mental health professional understand how the Internet has impacted these domains. Table 1 shows sample questions, grouped according to these domains, which can be used by a mental health professional during a face-to-face interview with a client. The questions shown in Table 1 are not meant to be a comprehensive set of items. These questions should be used as a basic sample of the types of questions that may help focus the mental health professional in screening for Internet problems. A thorough history of the client should be obtained, and a mental status exam should be completed. Asking additional questions and using other assessment instruments to measure difficulties such as risk taking, motivation level, anxiety, or
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TABLE 1. SAMPLE QUESTIONS FOR A SCREENING INTERVIEW ASSESSING PROBLEMATIC INTERNET USE Presenting problem 1. When did you begin to notice problems with your Internet use? 2. How long have you used the Internet? 3. What was going on in your life when you began using the Internet? 4. What was going on in your life when you began to have difficulties with your Internet use? 5. How much time do you spend on the Internet each day? Week? Month? 6. Do you ever feel preoccupied with the Internet (e.g., think about previous on-line activity or anticipate next on-line session)? 7. What is the longest amount of time you have spent using the Internet in one setting? 8. In what location does your Internet use occur? 9. What time of the day does the Internet use occur? 10. Who is around when you use the Internet? 11. What do you enjoy about the Internet? 12. What do you dislike about the Internet? 13. What Internet sites/applications (e.g., chat rooms, email, MUDS, instant messaging) do you use, and what effect do they have on you? 14. Have you ever stayed on-line longer than originally intended? 15. In what ways has your Internet use interfered with your daily activities? 16. Have you ever contemplated or tried cutting down on your Internet use but couldn’t? 17. What helps or makes the situation better? 18. What hurts or makes the situation worse? 19. Have you ever lied to family members, therapist, or others to conceal the extent of your involvement with the Internet? 20. How did you feel when attempting to cut down or stop your Internet use? 21. Why did you decide to seek help now? Biological areas 1. Are you experiencing any health concerns? If so, please describe. 2. How have these health concerns been impacted by your Internet use? 3. What treatment you have received for these health concerns? 4. Does your Internet use interfere with your sleep? (continued)
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TABLE 1. SAMPLE QUESTIONS FOR A SCREENING INTERVIEW ASSESSING PROBLEMATIC INTERNET USE (CONTINUED) 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
How many hours a night do you typically sleep? Does your Internet use interfere with eating regularly? How many meals a day do you typically eat? Have you recently gained or lost any weight? What exercise patterns do you engage in? What non-prescription medication do you take? How much? How often? What prescription medication do you take? How much? How often? What substances or behaviors do you or others feel you have been addicted to in the past? What kind of alcohol do you currently use? How much? How often? In the past? What drugs do you currently use? How much? How often? In the past? Is there a history of addiction in your family? If so, who and what?
Psychological areas 1. How do you feel before using the Internet? 2. What are your thoughts before using the Internet? 3. Have you ever used the Internet to help improve your mood or change your thoughts? 4. What is your environment like before using the Internet? 5. How do you feel while using the Internet? 6. What are your thoughts while using the Internet? 7. What is your environment like while using the Internet? 8. How do you feel after using the Internet? 9. What are your thoughts after using the Internet? 10. What is your environment like after using the Internet? 11. Have you ever felt anxious, depressed or isolated when off-line? 12. How well do you think you cope with various events in your life? Social areas 1. How has your Internet use caused problems or concerns with your family? 2. What psychological/psychiatric illnesses have members of your family experienced? 3. What is your overall degree of satisfaction with your family? 4. How has your Internet use caused problems or concerns with your significant other? 5. What is your overall degree of satisfaction with your significant other? 6. How has your Internet use caused problems or concerns with your child/children? 7. What is your overall degree of satisfaction with your child/children? 8. How has using the Internet caused problems or concerns with your social activities and friendships? 9. What is your overall degree of satisfaction with your friendships? 10. How do others in your life use the Internet (e.g., email, IM)? 11. What is your overall degree of satisfaction with school/work? 12. How has using the Internet interfered with your performance at school or work? 13. Have you ever been in trouble with the authorities because of your Internet use? 14. What are your social/leisure/hobby activities? 15. How would you rate your social skills? 16. How would you rate your communication skills? Relapse prevention areas 1. Do you believe that you have a problem with your level of Internet use? 2. What seems to trigger Internet use? 3. What do you see as the benefits and costs of continued Internet use? 4. What is your level of determination to change your current Internet patterns? 5. What plans have you implemented in the past to deal with your level of Internet use? 6. Have these plans worked?
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depression should be considered. Greenfield and Orzak43 state that this may be especially important if there is a concern about a comorbid disorder. Additionally, a referral to a physician for a medical evaluation should be made to rule out physiological problems that could be causing the current problems. The biological domain may include exploration into the client’s family history of addiction. Since some addictions have been linked to genes, this may provide support that the client has a biological predisposition for addiction problems. There may also be medical conditions as a result of excessive Internet use such as the person reporting little sleep, going for hours without eating, headaches, back and neck pain, carpal tunnel syndrome, and a decrease in one’s immune system.7–9 Minkoff and Drake44 commented that it is rare for a client to come to therapy and only have an addiction problem. Usually, there is some pre-existing psychiatric illness in addition to the addiction problem. The psychological domain can help to assess this possibility. The client’s thoughts and feelings while on- and off-line should be assessed in order to determine if there is psychological dependence. This could occur when numbing or pleasurable feelings are obtained from Internet use, which can be very reinforcing to the person. The social domain is used to determine how the Internet has impacted the client socially. This may be especially important since it is usually others in the addicted person’s life that recognize the problem and seek help for the user.10 This domain can also examine environmental aspects such as where the Internet use occurs and the types of applications used.
CONCLUSION Beard2 comments that mental health professionals need to be aware of this growing phenomenon, commonly called “Internet addiction,” and the role that we can take in addressing problematic Internet use and abuse. Difficulties with this new technology should be examined in a proactive manner rather then waiting for the crisis to occur and then “picking up the pieces.” Introducing new technology and simultaneously using psychology to counteract negative effects may lessen the onset of difficulties and the development of crises. Mental health professionals need to be alerted to the fact that many individuals may be reluctant to seek treatment, believing that the clinician will not take his or her difficulties seriously. Also, community mental health agencies, college counseling centers,
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and employee assistance programs should develop seminars and groups to increase community, staff, and employee’s knowledge of the effects of Internet use on the campus. Further, employee assistance programs should educate human resources managers how the Internet may affect employees, services that are available to the employee who demonstrates a problem with Internet usage, and other alternatives instead of suspension and termination.2,25 The continuing debate over the existence of Internet addiction will probably go on for some time. Regardless of whether or not Internet addiction is a true “addiction,” there are people developing a harmful dependence on the Internet. Likewise, there are many unknown factors remaining that need to be explored. What may be an appropriate assessment or intervention for one person may be different for another. This process is very complex but researchers are attempting to refine the numerous procedures and factors in assessing, diagnosing, and intervening with problematic Internet users.16 Hopefully, as this population of Internet users is examined, the means of understanding, evaluating, and treating them may become clearer and more effective.
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Address reprint requests to: Keith W. Beard, Psy.D. Psychology Department Marshall University 1 John Marshall Dr. Huntington, WV 25755 E-mail:
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