n this milestone, you will be reading this Case Study. In the previous milestone, you focused on the addiction and its effects. In Milestone Two, you will want to focus on the assessment used as well as the addiction. Consider the following in this paper:

Case study client information and presenting problem
Identify the client (gender, age, race, profession).
Identify the addiction that this client presents with.
Does he have a substance addiction, like alcohol, prescription drugs, or illicit drugs?
Does he have a process addiction, like gambling, video gaming, or shopping?
Assessment
Identify the physiological procedure the client uses for administration of his addiction (oral, injection, watching videos, phone calls).
Describe the type of environment in which the client spends his time.
Is there support within the family?
Does the client hang around with friends who are using addictive substances?
Is the client working for a company where his addiction is encouraged?
What is the client’s philosophical stand about his addiction?
What is his motivation level for getting help?
Is there a sense of hope or hopelessness?
Addiction information

Provide the history of the addiction. (Is it a substance or process addiction?)
What is the history of the addiction? Remember, there are many types of addiction, and not all were defined around that time. For example, video game addiction was not officially defined until 1995, while alcohol addiction was defined in 1941.
Differentiate between the physiological and psychological effects of the addiction.
Does the addiction physiologically affect the subject’s behaviors and mental processes? If so, how?
Does the addiction psychologically affect the subject’s behaviors and mental processes? If so, how?
Results

Discuss the results of this case.
Did the client respond positively to the treatment?
Did the client relapse?
Your paper should:

Be composed in MS Word and formatted in APA style
Be at least 3 pages in length, not including the title page and references page
Employ a minimum of two scholarly sources
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CASE STUDY!!
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Abstract
Internet game addiction is becoming a severe problem in adolescents. The purpose of this article was to present a case study on Internet game addiction. The effects of a new program to treat Internet game addiction based on cognitive-behavioral therapy, behavior modification, and a 12-step program are described. The subject in this case study was a 16-year-old Korean adolescent who lived in the United States. The adolescent received 5 counseling sessions which seemed ineffective in correcting his Internet game addiction. However, at follow-up, the adolescent showed improvement in game addiction. This article suggests that these 3 therapies could be combined to form a treatment model which could significantly benefit the patient and positively impact behavior change.

INTRODUCTION
Internet game addiction is becoming a serious problem in countries such as the United States or South Korea which have wide access to the Internet. The definition of Internet game addiction varies. Young (1996) defines Internet addiction as centralization of use of the Internet at the expense of other activities and putting priority on maintaining electronic relationships. DSM-V defines Internet addiction as: 1) excessive use, often associated with a loss of sense of time or a neglect of basic drives; 2) withdrawal, with feelings of anger, tension, and/or depression when the computer is inaccessible; 3) tolerance, with the need for better computer equipment, more software, or more hours of use; and 4) negative repercussions, with arguments, lying, poor achievement, social isolation, and fatigue (American Journal of Psychiatry, 2008). The prevalence of Internet addiction in South Korea varies from 2.3% in high school students (Choi et al., 2009) to 20.3% in adolescents (Ha et al., 2006). The prevalence of Internet abuse is 47% in high school students. Students with Internet addiction used the Internet for 3.5 hours (2.4) per day, while non-addicted students used the Internet for 1.7 hours (1.2) per day (Choi et al., 2009). A survey reported that 15% of 1,527 adolescents were classified as risky internet users. The more severe the Internet addiction, the more the use of games: 75.3% of the high-risk group used the Internet for games (Korea Agency for Digital Opportunity and Program, 2005). The prevalence of Internet addiction in the United States is from 0.3% in the general population (Shaw & Black, 2008) to 25% in undergraduate students (Fortson, Scotti, Chen, Malone, & Del Ben, 2007). Widyanto and McMurran (2004) reported that 86 young adults (mean age 28) spent 20 hours per week on the Internet for personal use.

Game addiction has negative effects such as loss of interpersonal relationships, failure to address responsibilities, distraction from other aspects of life, and poor health (Steward, 2004). Related factors of game addiction include hostility (Chiu, Lee, & Huang, 2004), little or no self-confidence (Griffiths, 2000), depression (LaRose, Lin, & Eastin, 2003), loneliness (Nalwa & Anand, 2003), low self-esteem, stress, impulsiveness (Cho & Lee, 2004), and low self-control (Song, 1998). Interventions for Internet game addiction include a value facilitation program (Jang, 2005), cognitive-behavioral therapy to increase self control (Lee, 2005), a self-growth program (Oh, 2004), self-control training (Kim, 2004), and a game desire control program (Pyo, 2003). Even though the effects of a 12-step program were evaluated on drug addiction, they were not evaluated on game addiction (Kristensen & Vederhus, 2005). Therefore, the purpose of this study is to describe a case study of a pilot intervention using a 12-step program combined with behavior modification and cognitive-behavior therapy to treat Internet game addiction in an adolescent.

INTERVENTION
Cognitive-behavioral therapy, a 12-step program, and behavior modification have all been reported as assisting in changing patients’ unhealthy behaviors. Cognitive behavioral therapy intends to change behaviors by changing beliefs. Individuals are required to analyze emotion, thought, behavior, and others situations when patients involve themselves in unhealthy behaviors. Individuals are required to analyze any underlying beliefs that may be untrue, unrealistic, or counterproductive (Magill & Ray, 2009). A 12-step program uses an informal bio-psycho-social-spiritual model (Craig, 1993). In 1996, the American Society of Addiction Medicine reported that a 12-step program demonstrated the ability to identify the problem, define the solution, and design a program of actions necessary to bring about recovery (Fajardo, 2006).

Behavior modification modifies behaviors using reinforcement, punishment, and extinction (eliminating the incentives for unwanted behavior) based on a learning theory that every behavior is learned by external conditions and learned behaviors are cancelled by learning. Token economy, which is designed to maximize effects in groups, helps a group gain tokens by acting out adaptive behaviors and encourages them to do more adaptive behaviors by exchanging tokens with a primary reinforcing agent (Lim, 2001).

CASE DESCRIPTION
A 16-year-old Korean adolescent, HC, was referred by his mother because of his negative attitude, depression, and overuse of the Internet. Even though he did not want to come to the US to live or study, his parents persuaded him to come here with his mother and brother. He has been in the US for 4 years. After coming to the US, he had difficulty speaking English. He withdrew from his friends. He started playing Internet games at the age of seven. The hours for playing games increased rapidly because he spent a lot of time alone after coming to the US. On the other hand, Koreans think manners are very important, especially between older and younger generations. While Americans call each other you regardless of their age, Koreans have many different words for expressing respect. HC has poor social relationships with his brother and Korean seniors because he does not use those respectful words. His mother worried about his negative attitude toward his father. For example, when his father visited him from Korea, and his father suggested something to do together, he usually answered negatively. HC expressed his need to reduce the hours of using games. He spent 3 to 5 hours on playing games on weekdays and 13 hours on weekends. He said that it was difficult to control, especially on weekends.

THE PROCESS OF INTERVENTION
Counseling consisted of five individual sessions that ranged in length from 30 minutes to 1 hour per week. Homework assignments were used to record HC’s activities and how he spent his time. Thoughts, emotions, and behavior that helped to control his desire to play games were explored. The counselor and HC discussed how to manage his time during the week and stickers were used as a reward when he kept his promise. Discussion using one or two questions based on a 12-step program took place (On-line game anonymous, 2006). In every meeting, he explained what he did well in the last week. A contract was made to teach him accountability. If he was not on time, he paid one dollar per every 10-minute period he was late.

Behavior Modification
The first session focused on obtaining a general assessment. The second session focused on the assessment of game addiction and creating a contract for behavior modification. HC agreed to try to reduce the time spent on games and increase time spent on other healthy activities. It was explained that stickers would be given as positive reinforcement and a prize would be given when he gathered an agreed-upon amount of stickers during eight sessions. His mother promised to give him half the money he needed for a new computer if he reached his goal. The contract was in written form and signed by HC, his mother, and a counselor (Table 1). Also, HC was asked to record the time spent on games and alternative activities on paper (Table 2). In the third session, his mother said that he had decreased game-playing time but showed agitation because of reducing the time spent on games. He spent less than 1 hour per a day on weekdays, but spent over 3 hours per day during the weekend. On a weekend, he did not go to school and did not have anything to do. He tried to talk with his mother and watched television dramas instead of playing games. He received 5 stickers for reducing his game time and 20 stickers for engaging in healthy activities. In the fourth session, he reached his goal for only 2 days. He said that he woke up early, did homework, fared well on his exam, and exercised. He got two stickers for reducing game time, but he could not remember spending time on healthy activities. He skipped two sessions because he slept late in the morning. His mother said that he sat up all night hanging out with his friends. In the fifth session, he did not reach his goal for even 1 day. He spent over 3 hours on games every day, but he tried to spend time on basketball, talking, and bowling with friends. He explained that he did not come the last 2 weeks because he thought it was too much trouble and the place for counseling was far away from his house. He was asked whether he had a desire to continue counseling or not. He avoided giving an answer directly. He was given 1 week to think about this. After contacting the counselor, finally he said that he wanted to give up.

TABLE 1
TABLE 1: Patient Contracting
TABLE 2
TABLE 2: Time for Games and Alternative Activities
Cognitive-Behavioral Therapy
HC was encouraged to be conscious of how his time was spent more on games than he intended and to explain which emotions, thoughts, and behaviors contribute to overuse of games. He was encouraged to think about which factors were helpful in reducing time spent on games. HC was asked to record his thoughts, emotions, and behaviors related to games on a form each week (Table 3). In the second session, discussion centered on the reasons, and disadvantages of playing games, methods to use to decrease time spent on games, and how to increase his holistic health. He played online games because it was fun; he could meet people through online games, and feel satisfaction when he reached the goals of game scores. He wanted to reduce time on computer games because it interfered with his studying and was not good for his health. In the third session, a screening tool for measuring his game addiction was given because he did not accept that he was addicted to computer games. He thought that if he wanted, he could stop. He was encouraged to express emotions, thoughts, and behaviors related to games. He always felt bored at home. When he felt bored, he usually played computer games. He could not drive. His mother and brother were usually outside until the evening or later and he was often alone on weekdays. Those situations contributed to his game addiction. In the fourth session, he forgot to bring his homework. He expressed feeling burdened to do his counseling homework. The idea of cognitive-behavioral therapy was good, but it was difficult for him to practice daily. As time went by, he had difficulty accurately writing down his exact hours on different activities. In addition, two pieces of paper every week were given: one for recording his activities and time, another for recording his emotions, thoughts, and behaviors related to games. It was difficult for him to keep the records and bring them to the sessions.

TABLE 3
TABLE 3: Cognitive-behavioral Therapy
The main issue for him was managing his boredom. A suggestion was given for him to do something different with his time. After the fifth session, he started to learn golf and he was becoming more interested in golfing. Therefore, he could reduce his time on games. He and his mother were encouraged to spend time outside doing something such as playing golf.

12-Step Program
Questions for each session were made based on the 12-step program (On-line game anonymous, 2006) (Table 4). For example, the goal of the first session was we admitted we were powerless over on-line gaming and that our lives have become unmanageable. The counselor offered three questions to approach this goal. Which part is difficult for you to control? Which part is easy for you to control? and Have you despaired about your failure of self-control? He doubted the existence of God because he prayed for something but God did not answer. Therefore he doubted God could help with his problems. He did not feel the need to pray. In the fourth session, what harm he caused to others was discussed. He said that he lied often in online games to sell his items at a high price. He said that he used abusive words because his friend used those words. He said he would try to reduce abusive words. He was encouraged to apologize to people whom he harmed by lying and using abusive words. In the fifth session, demerits in his character were discussed. He said that he felt difficulty accepting authority figures, often used abusive language, had perfectionism, and played games excessively. He thought that his perfectionism contributed to game addiction because he made a goal for game scores and he wanted to reach the goal. He was encouraged to think about the reasons he had difficulty having relationships with older persons. He heard that he should use respectful language and manners when he met Koreans. He said that he did not want to behave differently between Americans and Koreans. He felt that it was like having a dual personality. His counselor empathized that he would have difficulty living with the expectations of two cultures. He was encouraged to think about other’s perspectives. To have a good relationship with others, his counselor explained a need to act differently according to different cultural norms.

TABLE 4
TABLE 4: 12-step Program: One Powerful Step for Healthy Life
RESULT OF THE INTERVENTION
The program consisted of eight sessions originally. However, the counseling stopped after five sessions. During the counseling, there was some improvement. However, HC did not do his homework and did not keep his promise to reduce game hours. In the 2-month follow-up, his mother said that he had reduced his game time since he started golfing with her.

DISCUSSION
There are not many studies for intervention of Internet game addiction published in English. Young (2007) reported that cognitive behavioral therapy for eight sessions helped 114 middle-aged male patients to control Internet addiction. Collier (2009) introduced an inpatient therapy which consists of talk therapy, life-skills coaching, physical and nutritional education, work and home-maintenance skill-building, 12-step meetings, and feeding goats and chickens. There is no report of the effect of this program. Shek, Tang, and Lo (2009) reported the effect of an Internet addiction intervention program which consisted of a motivational interview, individual counseling, a peer support group, and family-based counseling. The authors reported that this Internet addiction problem decreased in 59 participants after participating in the program for 1519 months. Further studies are needed to develop interventions for Internet addiction and examine the effects.

Just as with other diseases, prevention is more important than treatment in the case of Internet addiction. Ko, Yen, Chen, Yeh, and Yen (2009) reported that attention-deficit/hyperactivity disorder, hostility, depression, and social phobia were predictors of Internet addiction. Therefore, screening attention-deficit/ hyperactivity disorder (ADHD), depression, hostility, or social phobia among children and adolescents is important to prevent Internet addiction. Medications are needed when depression or ADHD coexist with Internet addiction. Family intervention is needed to prevent Internet addiction. Park, Kim, and Choi (2008) reported that parenting attitudes, family communication, family cohesion, and family violence exposure were associated with Internet addiction. In this case, there was a lack of communication between the participant and parents. Education and counseling for parents is also important to prevent Internet addiction. For example, parents need to know how to have healthy communication with children, to have regular communication with their children, to check which Web sites their children often access. Parents have to put the computer in the living room not in the children’s room and encourage healthy outdoor activities. For the best result from counseling intervention, group therapy would be better than individual psychotherapy because adolescents tend to pursue fun with friends.

LIMITATIONS AND RECOMMENDATIONS
The burden of homework in cognitive-behavior therapy might cause subjects to resist participation in the counseling. To increase participation, the therapist could assign homework one day per week. Providing a binder for record-keeping would help the subject to remember to bring the homework to the session. The most important reason for HC stopping the sessions could be that this counseling was not fun for him. He had previously experienced having group therapy for ten sessions with friends. At that time he wanted to continue the group therapy and he showed interest. Group therapy would be more effective for Internet game addiction. The length of time for counseling is also important because addiction recovery is not easy to accomplish in a short period of time. At least eight sessions would be helpful for a game addiction problem (G. H. Kim, 2003; J. H. Kim, 2003)

REFERENCE
American Journal of Psychiatry. (2008). Issues for DSM-V: Internet addiction. American Journal of Psychiatry, 165(3), 306307.
Cited Here
Chiu, S. I., Lee, J. Z., & Huang, D. H. (2004). Video game addiction in children and teenagers in Taiwan. Cyberpsychology and Behavior, 7(5), 571581.
Cited Here