Behavioral Addictions _ _______________________________________________________________________
in adolescence can be both a cause and effect of cognitive, affective, and behavioral dysfunction.
CBT for Internet-mediated addiction (CBT-IA) addresses coping styles, Internet-related expectancies, attentional biases, cue-reactivity/craving, executive function, and inhibitory control. The patient’s Internet behavior is monitored and analyzed for situational, emotional, and cognitive contexts, and the reinforcing effects of Internet use are considered to help understand the cognitive assumptions and distortions that underlie situational triggers. CBT-IA identifies coping responses and high-risk situations for addictive Internet use, as well as the expectancies, illusions, and reinforcing effects. Cognitive restructuring and reframing target Internet-related cognitive biases [60]. Attentional biases can be decreased by attentional retraining. When combined with the computerized Go/No-Go task (a binary pass/fail test), this approach can improve inhibitory con- trol and executive functioning. Cue-exposure therapy is found to reduce conditioned associations and craving intensity [60]. CBT has evidential support as a treatment for several behav- ioral addictions. However, there is a nation-wide shortage of clinicians with specialized training in CBT in the United States. Even clinicians who believe they are delivering CBT- based interventions often do not deliver the core components
OVERVIEW OF GENERAL BEHAVIORAL ADDICTION TREATMENT PSYCHOLOGICAL THERAPIES Psychological therapies are the most extensively studied treatment approaches in behavioral addiction. The core com- ponents of many psychological therapies are applied across behavioral addictions, while other therapies are modified for specific addictions. This section gives a broad overview of psychological therapies used in the treatment of behavioral addictions in general. Tailored variants are discussed in later sections. As with any patients, it is important to assess for native lan- guage (or preferred language). Patients with lower English pro- ficiency will benefit from materials in their preferred language and/or the use of an interpreter. Cognitive-Behavioral Interventions Cognitive-behavioral therapies (CBTs) have evolved over the past 50 years. Behavioral therapy emerged as the “first wave” in the 1950s, followed by a second wave of cognitive therapy in the 1970s. Cognitive therapy and behavioral therapy were combined in the 1980s to become CBT. Since the mid-1990s, a range of third-wave approaches have been introduced, includ- ing acceptance and commitment therapy, cognitive-behavioral analysis system of psychotherapy, and functional analytic psychotherapy [71]. Cognitive-Behavioral Therapy CBT is empirically supported with demonstrated efficacy across a range of substance use disorders [72; 73]. CBT may work by strengthening executive control over behaviors through acquisition of cognitive skills. In behavioral addictions, CBT can help individuals improve their inhibitory control ability, recognize maladaptive cognitions, and learn and employ skills for more adaptive decision-making [74; 75]. CBT and CBT-related therapies can help patients identify distortions and errors in thinking and the mistaken, irrational beliefs that underpin maladaptive functioning. Patients learn to identify these distortions by monitoring their internal dialogue (e.g., “You can’t do that,” “Don’t even try”) and remembering childhood pronouncements (e.g., “You’ll never amount to anything,” “You’re lazy and stupid”) that compromise current functioning. Assessing the validity of patients’ conclusions and exploring different ways to view themselves and their capabili- ties are both potent CBT interventions. Through role-playing or in vivo exposure, patients can experiment with alternative views and behaviors. CBT-based approaches also teach coping skills, symptom management, relapse prevention, impulse control, and anger management [76].
of empirically supported CBT [77]. Cognitive Enhancement Therapy
As discussed, patients with behavioral addictions often show cognitive dysfunction involving elevated impulsivity, impaired cognitive control, and cognitive inflexibility, and therapies that target these domains may be helpful. Cognitive enhancement therapy (CET) involves the repeated practice of cognitive tasks involving problem-solving, response inhibition, visual tracking, and discrimination skills. These skills are practiced several hours per week over several months [57]. CET has resulted in significant improvements in impulsivity and delay discounting in patients with stimulant addiction, and similar strategies should be considered in targeting cognitive dysfunction in persons with behavioral addictions [78]. Cognitive Bias Modification Persons with gambling or Internet gaming disorder show atten- tional biases towards Internet cues, and therapies that target such biases may be effective as treatment [79]. Cognitive bias modification specifically targets automatic/implicit processes such as attention bias and approach bias. Mindfulness-Based Stress Reduction Stress intolerance and poor stress coping are strongly associ- ated with behavioral addictions. Mindfulness-based stress reduction interventions target stress reduction, and efficacy is supported in substance addictions. This approach may be particularly helpful in patients with behaviors driven by negative-reinforcement motivations [80].
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