King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). Cognitive behavioural therapy for problematic video game players: Conceptual considerations and practice issues. Journal of CyberTherapy and Rehabilitation, 3, 261-273. more

Journal of CyberTherapy & Rehabilitation F a l l 2 0 1 0 , Vo l u m e 3 , I s s u e 3 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e 261 COgNITIve behavIORal TheRapy fOR pROblemaTIC vIDeO game playeRs: CONCepTUal CONsIDeRaTIONs aND pRaCTICe IssUes Daniel L. King1, Paul H. Delfabbro1, and Mark D. Griffiths2 Cognitive-behavioral therapy (CBT) is rationalized to be a highly appropriate treatment modality for problem and addicted users of video games. Drawing on available empirical research in this and allied areas (e.g., problem gambling), this paper presents some preliminary treatment techniques that may be well suited to the known features, correlates, and consequences of video game addiction. These techniques involve monitoring video game use, setting appropriate goals, and overcoming problem cognitions that intensify and maintain video game use. Specialized knowledge of the structural and situational characteristics that develop and maintain problem video game playing is also provided. While problem video game playing appears to resemble pathological gambling in many ways, some distinct phenomenological aspects of video game playing prevent a direct translation of gambling CBT programs to video game players. It is suggested that further research is needed to provide further guidelines and treatment techniques for video game players who suffer problems with their behavior. There is also need for greater funding for more basic and applied research on problem video game players. Keywords: Video Game Addiction, Problematic Video Game Use, Problem Gambling Cognitive–behavioral Therapy INTRODUCTION Video game playing is an increasingly popular pastime among adolescents and adults around the world. However, a growing body of psychological literature reports that there may be some risks associated with very high levels of involvement in video game technology. In numerous studies, including large population survey studies (Charlton & Danforth, 2007; Fisher, 1994; Gentile, 2009; Griffiths, Davies, & Chappell, 2004a; 2004b; Grüsser, Thalemann & Griffiths, 2007; Rehbein, Kleimann & Mößle, 2010) and smaller-sized qualitative investigations (Chappell, Eatough, Davies & Griffiths, 2006; Griffiths, 2000; 2010a; Wood, 2008), a significant minority of video game players have been identified as problem or dependent users of the technology. These “problem” players reportedly jeopardize work or educational activities, social relationships, and personal well-being in order to play video games for periods up to 80 to 100 hours per week. Some researchers have referred to such high levels of involvement in video games as a form of behavioral addiction, comparable to pathological gambling (Griffiths, 2008a). Whether excessive video game playing behavior represents a unique disorder or a secondary problem arising from underlying pathologies, such as depression, remains Corresponding Author: Daniel King, School of Psychology, Hughes Building, The University of Adelaide, North Terrace, Adelaide SA 5005, Australia, Tel: (08) 830333740, E-mail: Daniel.King@adelaide.edu.au 1 2 School of Psychology, The University of Adelaide, North Terrace. Adelaide SA 5005, Australia International Gaming Research Unit, Psychology Division, Nottingham Trent University 262 Problematic Video Game Playing a subject of debate (Griffiths & Wood, 2000; Shaffer, 1996; Shaffer, Hall & Vander Bilt, 2000). Irrespective of its formal classification, the growing number of excessive users of video games suggests that it is an issue of significance for clinical and educational psychologists (Griffiths, 2010b). However, to date, there have been very few attempts to provide therapy-related information to meet the demand for psychological services among problem video game players. The position of this paper is that, while academic debate on the legitimacy of technologybased addictions continues, preliminary research and theory may guide the development of therapy techniques for excessive and/or problem video game players. RaTIONale fOR COgNITIve behavIORal TheRapy The cognitive-behavioral therapy (CBT) approach posits that faulty cognitive processes play a role in the development and persistence of maladaptive behaviors. Some studies have employed CBT techniques to assist problem users of the Internet and computer technology (Orzack & Orzack, 1999; Young, 1999; 2007). CBT has also been used with moderate to high levels of success in treatment studies for problem gamblers, who – at least conceptually – bear numerous similarities to problem video game players (Blaszczynski & Silove, 1995; Ladouceur, Boisvert, & Dumont, 1994; Sylvain, Ladouceur, & Boisvert, 1997; Petry et al., 2006). For instance, Fisher and Griffiths (1995) identified multiple structural similarities between electronic gambling machines and video games (e.g., flashing lights, sound effects, bonuses for skilful play, digital displays of winning scores, etc.). Griffiths (1991) went as far as to argue that some forms of video game playing (i.e., arcade machines) may be considered a non-financial form of gambling. Some playing differences between gambling and video game playing may have implications for the cognitive component of CBT. Unlike most gambling games, video games are not predominantly chance-based and involve a significant degree of skill and planning. Players of video games must be able to process and respond rapidly to in-game information, while negotiating obstacles, in order to make progress and “master” a video game. The emphasis on player strategy and hand-eye coordination means that a problem video game player is likely to hold rational thoughts and beliefs about video game playing and video game machines1. While video game players may think that, with sufficient skill and practice, there is a strong probability of being successful at a video game, problem gamblers often hold the mistaken belief that their own chances of winning in the long term are better than the objective odds of the game (Walker, 1992). Some cognitive therapy strategies (e.g., eliminating erroneous perceptions of the game, commonly used to treat problem gamblers) may therefore be less necessary for problem video game players. vIDeO game aDDICTION The field of technology-based addictions, including addiction to video games, has garnered significant interest from both the scientific and mainstream media community in the last three decades. However, despite this attention, the field has struggled to overcome a number of limitations and theoretical obstacles. There still exists some disagreement within the health community as to whether behavioral (non-chemical) addictions should even qualify as bona fide addictions. This debate has been complicated by somewhat imprecise terminology. The terms “excessive,” “problem,” “dependent,” “pathological,” and “addiction” have appeared numerously within the psychological literature on video game players – often without clear definition – leading to some confusion as to what these terms actually refer to. Therefore, it is not surprising that the construct validity of video game-related problems has been questioned. Wood (2008) has asserted that reports of individuals who play video games to the degree that it causes harm and/or conflict do not prove that these players are “addicted” to video games, only that they use the technology as an ineffective strategy for dealing with life problems. In order for video game addiction to be treated as a bona fide “addiction”, Blaszczynski (2008) argues that researchers must identify users who report not only problems resulting from sustained repetitive patterns of use, but also impaired control over their gaming behavior. The lack of clinical data (and overemphasis on the “negative consequences” of heavy video game playing) has led to the view that even the most damaging cases of video game overuse may be attributable to poor time management or underlying mental health issues, rather than a primary problem stemming from video game involvement itself (Wood, 2008). Arguably, however, the distinction between problem video game playing as a primary vs. secondary disorder is irrelevant from a clinical perspective. All forms of problem behavior, including addiction, are typically associated with co-morbid problems like depression – in fact, it would be unusual if an addict’s only problem was their addiction – and therefore any addicted behavior (or merely excessive behavior) would need to be addressed in therapy. Griffiths (2008) has also argued that, if clinicians can accept patho- 1 It should be noted that many slot machine players also believe their activity to be highly skilful, and that successful play involves speedy reactions, good hand-eye co-ordination, and forward planning (Griffiths, 1994). King, Delfabbro, and Griffiths logical gambling as a form of addiction (an addiction that does not involve the ingestion of a psychoactive substance), then why should video game playing as a potential form of addiction be treated any differently? There is no theoretical reason that prevents the criteria for addiction being applied to any and all repetitive and psychologically rewarding behaviors. Debating the merits of the addiction concept as it applies to all activities serves only to distract from the real issue: How does a person become addicted to video games? The relative risk of becoming addicted to an activity may be largely attributed to the inherent properties of the activity and the psychological characteristics of the individual. At a basic population level, it is argued that cocaine is more addictive than gambling, and gambling is more addictive than video game playing (West, 2006). Therefore, video game addiction is no less conceptually sound than cocaine addiction, but the actual risk of any given person becoming addicted to video games is relatively, and significantly, lower. Despite these conceptual issues, it has been stated repeatedly that many people report technology-based problem behavior, most commonly related to the Internet and/or video games (Griffiths, 1995; 2008b; Kaltiala-Heino, Lintonen, & Rimpela, 2004; Nalwa & Anand, 2003). Researchers have proposed a set of diagnostic criteria for addiction to the Internet as a type of impulse control disorder (Beard & Wolf, 2001; Shapira et al., 2003). More recently, a report by the Council on Science and Public Health (see Khan, 2007) recommended that “Internet/video game addiction” be considered by the American Medical Association for inclusion as a clinical diagnosis in the upcoming DSM-V. Addiction to the Internet is arguably a more imprecise concept than video game addiction, given the Internet may be used for many different purposes and activities, including gambling, social networking, browsing, and so on, and thus the Internet may simply enable and facilitate other addictions rather than being the root of the problem behavior. Internet-based disorders have not been officially recognized by either the American Medical Association or the World Health Organization. Despite this setback to technology-based addiction becoming a generally accepted concept, numerous studies of users of mobile phones (Bianchi & Phillips, 2005; Park, 2005; Beranuy, Oberst, Carbonell & Chamarro, 2009), social networking sites on the Internet (Song, Larose, Eastin, & Lin, 2004; Wilson, Fornasier & White, 2010), television (McIlwraith, 1998; Horvath, 2004) and video games (Fisher, 1994; Rehbein et al, 2010) have been conducted on the assumption that the standard 263 clinical criteria of addiction may be applied to these technological activities. The precise definition of what constitutes “problem” involvement in video games and other technologies is not just an issue of concern for empirical researchers. Clinical and educational practitioners also encounter difficulties in conceptualizing a client’s excessive video game playing behavior. In some cases, a person (or someone close to that person) may seek assistance to deal with an unmanageable video game playing habit (no other life problems or psychopathology are evident). In more complex cases, a person’s video game overuse may represent just one of many problem behaviors associated with, and triggered by, an underlying psychological problem. Some research has characterized excessive video game players as persistent procrastinators and time-wasters (Funk, Chan, Brouwer, & Curtiss, 2006), as social loners who prefer online interactions to real life relationships (Chappell et al., 2006), and as depressed/anxious individuals seeking an escape from their problems (Colwell, Grady, & Rhaiti, 1995). However, some authors have noted that excessive video game playing does not always lead to negative detrimental effects and in some circumstances may be socially beneficial for the players – at least in the relatively short term (Cole & Griffiths, 2007; Griffiths, 2010a). These different player profiles – both positive and negative – suggest that there may be various routes to becoming a problem user of video games, in a similar way that Blaszczynski and Nower’s (2002) pathways’ model has identified multiple routes to problem gambling. However, while empirical studies have found that players report a range of motivations to play particular video games (Griffiths, 1997; King & Delfabbro, 2009b), any such problem video game player typologies have not been examined empirically. Demographic research suggests that single males, in midadolescence to late-twenties, with computing experience, may be at the highest risk of developing a problematic habit with video games and/or other technologies (Griffiths, Davies, & Chappell, 2004a). However, the precipitating factors that lead to addictive involvement in video games have not been clearly documented. Case studies of “addicted” players suggest that habitual use of video games may develop rapidly and, due to the relatively low costs associated with the activity, a regular pattern of video game use may be easy to begin and maintain long term (Griffiths, 2000; 2008b; 2010a). Because video game playing tends to take place primarily in the home, the negative consequences of excessive playing (social isolation, JCR 264 Problematic Video Game Playing marital problems, etc.) are largely out of the public view and make it easier for problem players to hide their problems (Griffiths, 2008b). The privacy of video game playing also hinders and/or prevents naturalistic observation or in vivo examination of problem players’ thoughts and behaviors (King, Delfabbro & Griffiths, 2009). Another relevant issue concerning the study of technology-based addictions is the rapidly evolving nature of the technology. Since its inception, video game software has advanced at a highly rapid pace, with new and more sophisticated games being released every month (Spielberg, 2008). The term “video game” itself can be misleading, as video games encompass both online and stand-alone games, playable alone or with multiple other players. Each of these video game types is thought to be appealing for different reasons, and potentially attracts different types of players. New video game features (and even genres) are also being continually developed. Therefore, research on specific video games and their psychological appeal may become outdated within a relatively short time following initial publication. Psychologists who lack knowledge of the structural features and/or capabilities of modern video games may have some difficulty in understanding the changing motivations of those who play video games (King, Delfabbro, & Griffiths, 2010). ClINICal sTUDIes aND appROaChes To date, there have been very few clinical studies that assess the effectiveness of methods of treating problem video game playing. Some preliminary clinical studies have attempted to develop psychiatric profiles of excessive computer users. A study by Black, Belsare, and Schlosser (1999) reported that, in a sample of 21 compulsive users of computers, over half showed a co-morbid Axis I or Axis II disorder. These individuals used computers to alter their mood, either to feel more excited or powerful, or to assuage feelings of boredom, frustration or sadness. Attempts to reduce their computer use provoked strong feelings of anxiety. Interestingly, while computer use reportedly caused problems with work and relationships, none of the users felt that their compulsive computer use was significant enough to warrant any kind of treatment, echoing observations made in case studies of excessive video game players who have not sought treatment2 (Griffiths, 2000; 2010a). Another study by Yang (2001) identified a subgroup of 69 out of 1136 adolescents (6.1% of the overall sample) who met the criteria for video game addiction. These players experienced a deterioration of friendships, poor health symptoms, and interference with various life activities. Excessive users reported symptoms of obsessive-compulsive disorder, somatization and hostile behavior. Despite these “serious sociopsychiatric problems” (p. 217), Yang did not report what type of treatment, if any, might be appropriate for these problem video game players. In the largest ever study on video game play, a national German study assessed adolescent video game addiction in over 15,000 teenagers (Rehbein et al, 2010). They reported that 3% of the male and 0.3% of the female students were “dependent” on video games and that the data indicated a clear dividing line between extensive gaming and video game dependency as a clinically relevant phenomenon. The study also noted that dependency on video games was accompanied by increased levels of psychological and social stress in the form of lower school achievement, increased truancy, reduced sleep time, limited leisure activities, and increased thoughts of committing suicide. To date, two (now somewhat old) clinical case studies involving treatment of arcade video game addiction have been published. Kuczmierczyk, Walley, and Calhoun (1987) reported the case of an 18-year old college student who had been playing arcade video games 3-4 hours a day at an average cost of $5 (US) a day over a five-month period. Using a combination of self-monitoring, GSR (Galvanic Skin Response) biofeedback assisted relaxation training, in vivo exposure, and response prevention techniques, the researchers achieved a 90% reduction in playing behavior. This behavior change was maintained at sixand twelve-month follow-ups. In addition, the patient reported a more satisfying interpersonal life and significantly fewer anxiety symptoms. Another similar case reported by Keepers (1990) involved a 12-year old boy who played arcade video games for 45 hours per day at an average cost of $30-50 a day over a six-month period. The boy reported stealing money and truanting from school in order to play video games. In therapy, it was discovered that the boy was being physically abused by his father and played video games as a way of coping with strong feelings of helplessness. Following family therapy with the eventual outcome of the boy and the mother separating from the father, the boy’s emotional difficulties and excessive playing behaviors reduced significantly. A 6-month follow-up reported no ongoing issues. In both of these cases, the playing of video games was on arcade machines where the player had to ‘pay to play’. Behaviors that involve a financial cost may 2 Black et al. did not report whether participants later received any treatment for their problematic computer use. King, Delfabbro, and Griffiths incur more negative detrimental effects – particularly if the person goes beyond their own disposable income and resorts to criminal behavior to fund their activity. The lack of comparative treatment studies might suggest that, while a small minority of users (i.e., <1 to 3%) meet the clinical criteria for addiction to video games, there is a general lack of demand for psychological services for technology-based addictions. However, limited data suggest that this is not the case. An unpublished study by Woog (2004) surveyed a random sample of 5000 mental health professionals in the United States. Of the 229 completed surveys, two-thirds reported to have treated someone with problems related to excessive computer use in the previous 12-month period. Problem video game playing was most common among 11- to 17-year old clients. The need for further clinical research on video game addiction is evidenced by the growing international development of clinics that specialize in the psychological treatment of computer-based addictions, including: the Centre for Online and Internet Addiction located in Pennsylvania, United States; the Broadway Lodge residential rehabilitation unit located in Somerset, England; the Smith & Jones 12-step (Minnesota Model) clinic located in Amsterdam, Holland; and various government-run clinics throughout China. Each clinic has its own treatment philosophy and treatment techniques, but more popular approaches have included the 12-step approach (modeled on Alcoholics Anonymous), cognitive-behavioral therapy, motivational counseling, and interpersonal therapy (Griffiths & Meredith, 2009). Online support services for video game addiction are also becoming popular. For example, On-line Gamers Anonymous (www.olganon.org) offers self-help, online-based treatment based on the 12-Step Minnesota Model. The site’s online community provides practical advice and social support via its online forums. Success rates of these various approaches to treating video game addiction have not been made publicly available. assessmeNT The first step in dealing with a client presenting problem video game playing issues is to assess the nature and severity of the problem. Problem behavior is viewed in one of two ways: either as a categorical disorder or as an end-point on a continuum of psychological functioning. To date, the primary method for assessing video game addiction has been to use a checklist that measures addictive thoughts, behaviors, and consequences. It has been suggested that the amount of time a client spends 265 playing video games each week may also assist in framing a diagnosis (Woog, 2009). However, other researchers have argued that usage data is best regarded as background information because judging whether the amount of time a person spends playing video games is “excessive” essentially involves making a value judgement (Gentile, 2009; Griffiths, 2010a). While highly frequent use is generally more common among problem players, a person may spend over 35 hours per week playing video games without meeting any of the addiction criteria. Additional background information may also aid assessment, including: general health functioning (e.g., physical exercise, vitality, and sleep patterns), lifestyle factors (e.g., outside commitments, hobbies, structured activities) and any co-morbid psychopathology (e.g., depression, anxiety, stress). One method for assessing problem video game playing involves using Brown’s (1997) components model of addiction. This model states that addiction is defined by the following six features: (a) salience, meaning the person is preoccupied by thoughts of the activity at all times of the day, (b) tolerance, the process whereby the person must spend increasing amounts of time engaged in the activity to achieve former mood-modifying effects, (c) withdrawal, the unpleasant emotional state or physical effects that occur when the activity is suddenly discontinued or reduced, (d) relapse, the tendency for repeated reversions to earlier patterns of use, and for even extreme patterns of use to be restored quickly after periods of abstinence or regulation, (e) mood modification, the subjective experience (e.g., an exciting “buzz” or tranquilising “numbing”) associated with engaging in the activity, and (f) harm, the conflict between the user and those around them, including work, school, hobbies, and social life. A person who meets some of these criteria may be considered a “problem” user, and those who meet all six criteria may be considered “addicted” (Griffiths, 2008a). Another method for assessing problem video game playing is to use the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) classification for pathological gambling (American Medical Association, 1994). These criteria have already been adapted by researchers to identify pathological video game players (e.g., Fisher, 1994; Griffiths & Hunt, 1998; Salguero & Moran, 2002; Gentile, 2009). Using these criteria, the presence of video game addiction may be indicated by five (or more) of the following criteria: 1. Preoccupation with video game playing, including re- JCR 266 Problematic Video Game Playing living past playing experiences, or planning the next opportunity to play 2. The need to play for increasingly longer periods of time in order to achieve the desired excitement 3. Repeated unsuccessful efforts to control, cut back, or stop video game playing 4. Restlessness or irritability when attempting to cut down or stop video game playing 5. Playing video games as a way of escaping from problems or of relieving feelings of helplessness, guilt, anxiety, depression 6. After losing in a video game, returning another day to make more progress or get a higher score (“chasing”) 7. Lying to family members, therapist, or others to conceal the extent of involvement with video game machines 8. Committing illegal acts, such as theft, in order to finance video game playing 9. Jeopardizing or losing a significant relationship, job, educational or career opportunity because of video game playing 10. Needing another individual to provide money to relieve a desperate financial situation caused by video game playing Some researchers have investigated video game addiction by adapting the ICD-10 (World Health Organization, 2000) diagnostic criteria for pathological gambling (Grusser, Thalemann & Griffiths, 2007). Additionally, some self-report measures have been developed for identifying problem users of video games. For instance, Yang (2001), Hussain and Griffiths (2009), and King, Delfabbro and Zajac (2010) developed measures of problem video game play (the Problem Video Game Playing Test [PVGT], the Video Game Addiction Inventory [VGAI] modeled on the Exercise Addiction Inventory [Terry, Szabo & Griffiths, 2004] and the Computer-Related Addictive behavior Inventory [CRABI], respectively) modeled on Young’s (1998) Internet Addiction Test. These measures were based on standard clinical criteria, with higher scores indicating greater risk of video game-related behavior problems. Lemmens et al. (2009) recently devel- oped the Game Addiction Scale (GAS). This self-report measure includes items representing seven DSM-based criteria for game addiction that had been identified in earlier research. Despite their ongoing use in empirical research, the PVGT, VGAI, CRABI and the GAS have not been clinically validated so their test score data should not be considered a formal clinical diagnosis. Client motivation for seeking psychological assistance should also be considered during assessment (Blaszczynski, 1998). Some clients may deny that they have a problem video game playing habit, despite being faced with significant adverse consequences of their excessive behavior. Similarly, some clients may think that their partner or spouse’s complaints, rather than their own behavior, are the real problem to address in therapy. If clients refuse to take personal responsibility for their problem behavior, or feel that treatment is unnecessary, then it is unlikely that any productive treatment will follow. TReaTmeNT The cognitive-behavioral approach posits that psychological problems stem from problematic cognitions coupled with behaviors that either intensify or maintain the maladaptive response. Treatment involves identifying problem cognitions and replacing them with new beliefs, attitudes, and strategies that promote healthy behavioral change (Leahy, 2003). While a comprehensive treatment plan for video game addiction is far beyond the scope of this paper, we put forward a basic, and tentative, foundation for therapeutic practice. These techniques are drawn from multiple resources for CBT practice, including treatment handbooks and research papers on treating adolescent problem gambling (Blaszczynski, 1998; Dobson, 2001; Gupta & Derevensky, 2000; Leahy, 2003). In addition, research literature is used to guide those practitioners who may be unfamiliar with the psychological aspects of video game technologies. While the video game addiction treatment stages described are not supported by rigorous, scientifically controlled research studies, this brief program is presented so that further work may validate and expand upon its clinical utility. mONITORINg Use Monitoring involves steering clients to become more aware of the problems associated with their excessive video game use (Woog, 2009). This involves drawing attention to the adverse consequences of excessive playing, such as loss of sleep due to playing video games, relation- JCR King, Delfabbro, and Griffiths ship tensions, neglect of other commitments (e.g., work, educational activities, household duties, and/or exercise), frustration at being interrupted when playing, or depressed feelings when not playing. Successful monitoring has two main client outcomes: (a) additional motivation to change because video game-related problems are more salient and tangible, and (b) greater insight into the self-perpetuating cycle of problem video game playing (i.e., excessive play creates problems that the client seeks to escape from by playing video games). The client can then identify situations that trigger or increase vulnerability to play video games (e.g., after a fight with a partner, when homework gets too difficult, etc.). In this way, monitoring information provides the foundation for setting goals that promote healthier involvement in video games. Blaszczynski (1998) recommends that problem gamblers maintain a log of daily use, taking note of their thoughts and emotions during a playing session as well as during periods when not playing. This technique may be easily adapted to video game playing. Monitoring playing habits enables the client to confront thoughts of denial (e.g., “I do not play video games very often, maybe just an hour or two a night”) as well as develop a greater sense of personal responsibility (e.g., “I need to be more accountable to myself because I am playing more that I intend”). Clients should be encouraged to monitor the number of hours spent playing video games each night, as well as their thoughts and emotions when playing. Given the continuous nature of video game play, a person may lose track of time and subsequently incorrectly estimate the amount of time spent playing (Charlton & Danforth, 2007). Some video games feature a playing counter that records hours played on each day or playing session, which should make the task of monitoring less fraught with human error. In addition to raw playing time, clients could be encouraged to record the number of failures, mistakes, and wasted opportunities made while playing a video game, along with associated times spent reloading the game following a game-ending failure. Loading screens can range between a few seconds to a few minutes. The longest loading times often occur in online games where the player waits in a “lobby” for other players to join the game or for game content to download before the game begins. Loading times are not always tracked by a video game’s internal clock, which means that the player may think they have played for less time than is the case. Therefore, monitoring exercises should aim to provide the client with experiential feedback on how much time is spent in the video game without gaining any satisfaction. 267 gOal-seTTINg The overarching goal of therapy is to reduce the amount of time spent playing video games to levels that no longer interfere with the client’s well-being and life functioning. This may include total abstinence from video games, abstinence from specific video games that produce excessive involvement, or playing video games but in a controlled manner. In particular, players of massively multiplayer online role-playing games (MMORPGs) often report the greatest difficulty managing time spent playing as compared to players of other games (Ng & Weimer-Hastings, 2005). This difficulty can be largely attributed to the social obligations and complex reward systems in these games. Total abstinence from online games may be a difficult goal because numerous other players may rely on the client to be available to regularly play the game for mutual benefit. In addition, the client may frequently socialize with other players as part of being a member of a social group such as a “clan” or “guild”. The social elements in these groups provide a sense of identity and belonging for the player, thus making it difficult to completely disconnect from this social network (King et al., 2010). A therapist could assist the client to develop and rehearse ways in which he or she will inform playing partners of their decision to reduce time spent playing, and avoid feeling pressured socially into playing the game. In addition, the client may need to address conflicting negative emotions related to no longer making progress in their favorite video game as a result of meeting goals to reduce excessive playing behaviors. Many players become emotionally attached to their in-game character(s) after spending months playing the video game. Some treatment clinics have recommended that quitting players should delete their video game characters as a way of making their departure more permanent and any potential return to the video game less immediately appealing. In addition to setting limits on use, clients need to develop practical ways to overcome or avoid any obstacles to their treatment goals (Leahy, 2004). A client may work in a highly stressful job and play video games every night for 5-6 hours as a coping mechanism for stress. In this example, job-related stress triggers the need to play video games. Setting limits on video game use may be effective, but the client should also develop some alternative ways of dealing with stress, particularly activities that foster a sense of achievement rather than an escape from negative mood states. Woog (2009) recommends that clients in the early stages of reducing computer use should: (a) engage in healthy lifestyle choices, such as increasing sleep and eating at regular meal times, (b) stop complementary re- JCR 268 Problematic Video Game Playing wards that promote computer use (e.g., buying new computer equipment, reading video game magazines and online forums), (c) minimize deliberate exposure to situations that initiate video game playing, and (d) making video game playing less convenient and accessible in the home environment (e.g., unplugging a video game console and packing it away after use). If a client has concurrent symptoms of depression or other mood disorders, then additional therapy for these psychological issues should also be considered. For instance, problem players with social anxiety issues may benefit from assertiveness or similar social skills training. Similarly, helping the client to find other avenues of social support may reduce feelings of isolation from spending less time playing video games. Addressing the situational context is also important during the goal-setting stage. Although video games may be played at internet cafes and other video gaming venues, most video games are played in the home environment (Brand, 2009). For this reason, video game playing is largely private, unsupervised, and unregulated. There are no “opening hours” - video games are available to play 24 hours per day, seven days per week, 365 days of the year. Jacobs (1986) argued that, as an addiction develops, a person makes major changes to their lifestyle, including modifications to their environment, in order to facilitate a behavioral repertoire that extends gratification from the activity. For problem video game players, this process may involve arranging the home living space so that all other activities, like eating, sleeping or socializing, are able to revolve around (and without causing interruption or impediment to) use of the centralized video game machine. In therapy, clients need to develop ways of separating the playing experience from other activities in the home environment to avoid continual, uninterrupted use, and/or determine new places to play video games that are more public, visible, and time-limited. DealINg wITh pROblem COgNITIONs One of the main objectives of CBT is to challenge faulty cognitions that maintain problem behavior and replace them with more adaptive thoughts that promote healthy behavior. However, video game playing mostly involves rational, rather than illogical, thought processes. In a video game, a player must use skill and knowledge of the game to make progress and earn rewards. Studies have shown that the appeal of video game playing for many players includes attempting to reach the highest possible experience level, beating the highest score, and/or finding the best items in the video game (King & Delfabbro, 2009a; Wood, Griffiths, Chappell, & Davies, 2004). As video games have become increasingly complex, with more sophisticated reward systems that require the cooperation of many players, significantly more thought and planning (and time) are required to master a video game. For example, in the online role-playing game World of Warcraft, some players may play five nights a week, over a period of months, in order to acquire one single reward. The proliferation of online forums, magazines, and guidebooks dedicated to video game strategy suggests that players are aware of the procedural steps and time required to find rare game items or reach the next level in a game. King and Delfabbro (2009a) observed that many players attempt to optimize their reward payout in some video games by performing simple, repetitive actions that provide a small, but consistent, reward (a practice known by players as “grinding”). While this behavior may be considered “rational,” few players report to enjoy the process of grinding and playing video games in this way has been referred to a “second job” (King & Delfabbro, 2009a). Because player skill and strategy (or grinding) theoretically allows players to obtain all of the thousands of rewards in a video game, problem players may be motivated indefatigably to acquire every single reward in the video game3. In this sense, the video game may be compared to a slot machine that, with enough time and practice, will almost certainly deliver a jackpot. For problem players, the process of completing a video game may be rationalized as time well spent, in spite of the negative consequences of excessive playing. King and Delfabbro (2009b) found that problem players’ motivations to play video games differed significantly from regular players. Problem players were more motivated by the rewards in video games, as well as the release of tension and approval of others when playing a video game than regular players. Problem players also scored higher on a measure of “amotivation” (a feeling of meaninglessness when playing) than normal players. Cognitive therapy for problem video game players should address the client’s thought processes that compel the player to be preoccupied with playing the video game until it is complete. A cognitive therapy exercise may involve the client recording their motivations for playing video games (e.g., enjoyment, learning strategy, and feeling a sense of achievement) and then having the client evaluate, action by action on a playing session-by-session basis, whether the video game regularly satisfied these motivations. Through therapy, clients may reach a self-under- 3 Some video games, by design, can never be completed because they have virtually unlimited rewards. These games may be comparable to a slot machine that never delivers a jackpot. King, Delfabbro, and Griffiths standing that they no longer play the video game for fun or enjoyment, but simply to reach the next level or reward. Psycho-education may also be useful in therapy. For example, a therapist could teach the client that the appeal of video games, like electronic gambling machines, can be explained by the operant conditioning paradigm (Ferster & Skinner, 1957). Video game developers design their video games to reward players at frequent intervals in the early stages of the game, and significantly less so in later stages. Therefore, as the player makes progress, rewards are delivered more infrequently and often less predictably. As a result, many video game players, like gamblers, are motivated to continue playing because the next reward may be “just around the corner” (Griffiths & Wood, 2000). Building the client’s understanding of how fixed and variable reinforcement schedules promote player beliefs and expectancies about reward payout – and, specifically, that video games become less “fun” the longer a player spends in the game – may lead to a critical evaluation of the amount of time spent playing the game without enjoyment. Despite appearing largely rational, some aspects of problem video game playing may be maintained by irrational, misguided or faulty cognitions. For example, the rewards of competition – like a high score after beating an opponent using superior strategy – has long been recognized as a key appealing feature of video games (Vorderer, Hartmann, & Klimmt, 2003). Like problem gamblers who attempt to overcome the odds and “beat the house”, some problem video game players may become preoccupied with beating a high score held by an opponent. Prior to online video games, video games were predominantly played by a local group of players at a fixed location (e.g., an arcade machine in an amusement center). In this context, the player had only to beat a modest number of opponents in order to become “the best”. In contrast, modern online video games may be played by a global audience of millions at any given time via broadband service. In online games, player scores are tracked on a global leaderboard that ranks all players in terms of their highest achievements in the game (King, Delfabbro & Griffiths, 2010). This collation of international data makes it extremely difficult for any player to excel at a particular video game. Competitiveness may drive players to become preoccupied with their global ranking in the game, and create an belief that, despite the odds, they will beat all other players at the video game – just as problem gamblers may believe that they are able to beat the casino. While not strictly impossible for a video game player, the 269 time and skill required to achieve this goal may extend beyond that which the majority of players can devote to the game without creating conflict in other areas of their life. Superstitious thoughts about video game rewards may also contribute to problem use of video games. An unpublished study by Yee surveyed 380 regular players of online video games and found that players reported a number of irrational beliefs about video games, including: (a) certain video game characters or classes are “luckier” than others, (b) randomly delivered rewards could be influenced by the order in which players approach and reveal the reward, (c) certain items in the video game, such as clothing or weapons on characters, act as a “lucky charm”, and (d) random number generators that determine reward payout or “item drop” operated in predictable patterns, rather than random sequences. While Yee’s findings are of a preliminary nature, they suggest that some video game players may hold irrational and/or superstitious beliefs similar to those among problem gamblers (Griffiths, 1994; Griffiths & Bingham, 2005). These problem cognitions should be addressed in therapy if they relate directly to problem playing behavior (e.g., the client believes that playing uninterrupted for many hours will yield greater in-game rewards). CONClUsION Although technology-based addictions have received increased academic and media attention in recent years, there is still a dearth of both clinical and empirical literature on problem video game playing and addiction. The research base is particularly limited with regard to methods of treating problem users of video games. Based on its many previous applications to treating behavioral addiction, CBT is rationalized to be a highly appropriate treatment modality for video game addiction. Drawing on available empirical research in this and allied areas (e.g., problem gambling), this paper has outlined some conceptual considerations and therapy issues in relation to the known features, correlates, and consequences of video game addiction. While problem video game playing appears to resemble pathological gambling in many ways, there are also some distinct cognitive elements of video game playing that prevent a direct translation of gambling CBT programs to video game players. The current knowledge base on problem video game play indicates that there is a need for more basic and applied research on problem video game players. In addition, longitudinal research is needed to add greater empirical weight to the claim that excessive video game playing represents a persistent and significant psychological problem. JCR 270 Problematic Video Game Playing RefeReNCes American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC: Author. Beard, K.W., & Wolf, E.M. (2001). Modification in the proposed diagnostic criteria for Internet addiction. CyberPsychology & Behavior, 4, 377–383. Beranuy, M., Oberst, U., Carbonell, X. & Chamarro, A. (2009). 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