Cognitive Behavioral Therapy PDF

Cognitive Behavioral Therapy Serena M. King, PhD., LP| Powered Up | Module #  01. Complete overview of model 02. Unde...

Cognitive Behavioral Therapy Serena M. King, PhD., LP| Powered Up | Module #  01. Complete overview of model 02. Understand key components of Objectives model as they relate to Internet Use Disorder and Gaming Disorder 03. Examine research of model 04. Apply model to clinical setting 05. Complete knowledge check quiz Serena M. King PhD | Powered Up | Module #3 Overview  Cognitive Behavioral Therapy Overview Foundational Concepts: Cognitive Behavioral Therapy is a form of therapy that is focused on the relationships between feelings, thoughts, and behaviors. A recent meta-analysis suggested that CBT and mindfulness-based therapies are among the highest performing therapies for Excessive Gaming (Kim et al., 2022) Core Principles involved (Kim et al., 2022) – Behavior modification to control compulsive internet use or gaming – Cognitive restructuring to identify, challenge, and modify cognitive distortions that lead to addictive use – Harm reduction techniques to address and treat co-morbid issues associated with the disorder. Serena M. King, PhD| Powered Up | Module # 3  Cognitive Model (Compulsive Internet Use) Cognitive distortions including self-doubt, low self-efficacy and negative self-appraisal. In a negative self view, the internet to achieve more positive responses from others in a non-threatening way. Cognitions about the self may include such thoughts as: – “I am only good on the Internet (or gaming),” “I am worthless offline, but online I am someone,” and “I am a failure when I am offline.” Distortions involved generalizing specific to global. – “The Internet is the only place I am respected,” “Nobody loves me offline,” “the Internet is my only friend,” or “People treat me badly offline.” All-or-nothing thinking is considered a maladaptive cognitive distortion These distortions of thought are automatically enacted whenever a stimulus associated with the Internet is available. Therefore, immediately upon entering a chatroom, the individual automatically (and unintentionally) enacts these cognitions. Problematic Internet Use is assumed to be the result of pre-existing psychopathology, which becomes associated with online activity. Presenter’s Name | Powered Up | Module #3 Key Components  Goal Setting: CBT framework Address conflicting negative emotions experiences by the client. Many players become emotionally attached to their in-game char- acter(s) after spending months playing the video game. Some treatment clinics suggest quitting players should delete their video game characters as a way of reducing the chance to going back because of that appeal Time limits on use Practical ways to overcome barriers Case: “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 feelings and emotions. mood states.” (King et al., 2010) King, Delfabbro, & Griffiths, 2010 Serena M. King PhD| Powered Up | Module #3  Habit Loops of Compulsive Behaviors in a CBT model Trigger Something in the environment starts the thought or behavior, reminders, or cues. Behavior It is the behavior itself, in this case, compulsive or disordered gaming or internet use, can be self-reinforcing and rewarding Result How we feel after the behavior or during Presenter’s Name | Powered Up | Module # 3  Essential Components: Monitoring Self Monitoring is an essential component to CBT for GD. Monitoring can involve tracking the length of time spent in play and self-monitoring engagement. This is made up of: 1. motivation to change 2. insight into behavioral patterns of problem video game playing 3. modification of situations that increase vulnerability to pl King, Delfabbro & Griffiths, 2010 Serena M. King PhD| Powered Up | Module # 3  Psychoeducational Strategies Teaching of behavioral reinforcement strategies in games Training that the attractiveness of video games, similar to electronic gambling machines, can be explained by the operant conditioning Video game developers design their games to reward players at frequent intervals in the early stages of the game, and significantly less so in late stages. As the player makes progress, rewards are delivered more infrequently and often less predictably. Problematic video game players may be motivated to continue playing because the next reward may be soon. Education on 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. King, Delfabbro & Griffiths, 2010 Presenter’s Name | Powered Up | Module # 3  Key Components: Behavioral Modification Behavioral Modification: – Time limiting – Pre and post-behavioral monitoring of triggers – Structuring conditions of environment and emotion to prevent the urges to use – Daily diary tracking of behaviors – Pre-internet and gaming behaviors and setting environmental and modifications to create boundaries – Positive responses (reinforcing nature) of the use of gaming or internet leads to a self-reinforcing pattern of use)- break the cycle of association. – Motivation to change-what can I gain, motivating to provide an alternative behavior=what else can I be doing? – Alternative responses to stress or escape urges King, Delfabbro & Griffiths, 2010 Serena M. King, PhD. | Powered Up | Module #3  Examples of Behavioral Modification Strategies Substitution: swapping gaming for other activities and rewarding those changes) Lifestyle change and refocusing: making major changes to lifestyle such as routine and life focus Consumption control: setting mechanisms in place to support limit-setting while gaming – Clinical Examples: Generating alternative activities to substitute Integrating focus on mindful cognitions that focus on present moment and prioritizing goals Environmental strategies to change tendencies to engage in gaming Park et al., 2020 Serena M. King, PhD| Powered Up | Module #3  Situational Context: Behavioral Approaches Video game playing is largely private, unsupervised, and unregulated. In therapy, – clients need to develop ways of separating the playing experience from other activities – And depending on comfort and situation: consider whether one could engage in new places to play video games that are more public, visible, and time-limited. King, Delfabbro & Griffiths, 2010 Serena M. King PhD | Powered Up | Module # 3  Key Components: Cognitive Restructuring Overemphasis on gaming rewards, experiences, and identities Maladaptive and inflexible rules about gaming behaviors Video-gaming to maintain self-esteem Video-gaming for social status and recognition Preoccupation as a core cognitive symptom Gambling versus gaming: Gambling: cognitive interventions for gambling focus on addressing erroneous beliefs relating to randomness, chance and probabilities. Gaming: “excessive video game playing is probably best understood as maladaptive form of coping in which video game activities, virtual identities and rewards come to be over-valued and to compensate for negative core beliefs and feelings of dissatisfaction in other areas of life.” King and Delfabbro, 2015 Serena M. King PhD| Powered Up | Module #3  Delfabbro & King, 2015 Serena M. King, PhD| Powered Up | Module #3  Problem Player Cognitions More motivated by: – rewards in video games – release of tension – approval of others when playing a video game – Scored higher on a measure of “amotivation” (a feeling of meaninglessness when playing) than normal players. King, Delfabbro, & Griffiths, 2010 Presenter’s Name | Powered Up | Module #3  Cognitive restructuring of common cognitions “I will be able to concentrate on my homework once I have completed this level” (King & Delfabbro, 2015) – In response a restructuring exercise could be– challenging this thought– by doing a behavioral experiment – Conditional statements- if, then– creating some cognitive flexibility around the self-talk – If I reset---stop and limit and refocus, can I get more work done and then later on when the work is done, I can create time limited structure to engage after completion. Clients may use video games to escape from other commitments (“I can’t face homework and class, it’s too hard, but I know I can beat everyone in this game”(King & Delfabbro, 2015). Is winning the game working toward goals and priorities in your life that are important? Behavioral experiment with small accomplishments with completion of homework-providing rewards Serena M. King PhD| Powered Up | Module #3  ‘Sunk Costs’: Thinking Pattern Sunk costs are over investment of time, money or effort in an activity and one which you have made an overinvestment Gamers encounter goals to reach checkpoints, or a natural end of a game (e.g., level, quest, or mission). Abandoning a game can be seen as a ‘lost’ investment of in-game progress, which might vary from a few minutes up to many hours of gaming time. In large, complex and/or online video-games, such as massively multiplayer online games (MMOs) and role-playing games (RPGs) – Understanding the cognitions related to these sunk costs can help clients put the games in perspective- normalizing feelings and helping to speak back to those thoughts may be useful for some clients Delfabbro & King, 2015 Serena M. King, PhD| Powered Up | Module #3  ‘Tolerance for Uncertainty’: Thinking Pattern TFU as the name implies, refers to a person’s inability to cope with situations where decisions are made with incomplete knowledge or where some task or situation remains unresolved In general, those people who score higher on this measure also score higher on measures of anxiety, depression and rumination. Problematic gaming clients may have risk factors related to this and gaming environment allows for more control – In this context, gamer’s recognition of the thoughts and behaviors related to having trouble tolerating uncertainty may help them to have insights in their own ways in which this manifests in an over focus on gaming Serena M. King PhD| Powered Up | Module #3  Self-Worth and Acceptance: Thinking Pattern Gamers may tend to place a high value that players place on their virtual roles and sense of belonging within the social world of video-games. A person’s self worth may be immersed in social functions and accomplishments online and then the rewards in non-online interactions may be harder to come by Self-worth and value may be increasingly tied to game play. Delfabbro & King, 2015 Serena M. King PhD| Powered Up | Module #3  CBT Exercise: Experiment 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). Client evaluates, action by action on a playing session-by-session basis, whether the video game regularly satisfied these motivations. King, Delfabbro, & Griffiths, 2010 Serena M. King PhD| Powered Up | Module #3  Identifying and Challenging Cognitive Distortions Thought Records: Clients keep a journal to track their thoughts, feelings, and behaviors related to gaming. They identify and challenge negative thoughts (e.g., "I'm a failure if I don't win," "I need to escape reality through gaming"). Cognitive Restructuring: Clients learn to identify and challenge irrational or distorted thinking patterns. Techniques include: Reality Testing: Examining the evidence for and against negative thoughts. Decatastrophizing: Imagining the worst-case scenario and then evaluating the likelihood and impact of that outcome. Reframing: Looking at situations from a different perspective. Identifying Underlying Beliefs: Clients explore core beliefs about themselves, others, and the world that contribute to their gaming problems (e.g., "I'm not good enough," "The world is a dangerous place"). Presenter’s Name | Powered Up | Module #3  Behavioral Interventions Graded Exposure: Clients gradually reduce their gaming time through a structured plan. They may start with small reductions and gradually increase the duration of breaks from gaming. Competing Activities: Clients identify and engage in alternative, more rewarding activities that compete with gaming for their time and attention (e.g., hobbies, sports, social activities). Skill-Building: Clients learn and practice essential life skills such as: Stress Management Techniques: Relaxation, mindfulness, deep breathing. Assertiveness Training: Communicating needs and boundaries effectively. Problem-Solving Skills: Identifying and addressing challenges in a constructive way. Social Skills Training: Clients may benefit from social skills training to improve their social interactions and build stronger relationships. Presenter’s Name | Powered Up | Module #3  Relapse Prevention Identifying High-Risk Situations: Clients identify situations that trigger excessive gaming (e.g., stress, boredom, social isolation). Developing Coping Strategies: Clients develop and practice coping strategies for high-risk situations (e.g., engaging in alternative activities, seeking social support). Identifying Early Warning Signs: Clients learn to recognize early warning signs of relapse and develop a plan to address them. Presenter’s Name | Powered Up | Module #3 Research  CBT Intervention Research Pre-Intervention Pre-Intervention for Adolescents for Gaming Disorder using a CBT for Youth Framework Effectiveness of Psychological treatments for excessive gaming: A systematic Therapies review and meta-analysis Integrated Effectiveness of an integrated motivational cognitive-behavioral Motivational CBT group intervention for adolescents with gaming disorder: group intervention a randomized controlled trial for adolescents Serena M. King PhD| Powered Up | Module #3  Pre-Intervention Effectiveness of Cognitive Behavioral Therapy–Based Intervention in Preventing Gaming Disorder and Unspecified Internet Use Disorder in Adolescents A Cluster Randomized Clinical Trial (Lindenberg et al., 2022) The preventive short intervention (PROTECT) for group settings involved four modules (1) boredom and motivational problems (2) procrastination and performance anxiety (3) social interaction (4) emotion regulation Serena M. King PhD | Powered Up | Module #3  Therapy Effectiveness Psychological treatments for excessive gaming: A systematic review and meta-analysis (Kim et al., 2022) Top three ranked interventions – CBT + Mindfulness – CBT + Family intervention – Mindfulness – “were statistically significantly superior to CBT as a standalone treatment as well as the rest of treatments” (Kim et al., 2022) Serena M. King PhD | Powered Up | Module #  CBT effectiveness in group context (IMCBT) Effectiveness of an integrated motivational cognitive-behavioral group intervention for adolescents with gaming disorder: a randomized controlled trial (Ji & Wong, 2023) Integrated cognitive-behavioral therapy with a strength-based motivational approach [ (ICBT)] intervention to change gaming disorder (GD) 8 weekly sessions The content of the ICBT included: – group rules and understanding participants’ gaming patterns; – understanding participants’ maladaptive cognitive evaluation of gaming and developing cognitive reconstruction strategies to modify the cognitions – identifying participants’ strengths and interests, brainstorming the desired life goals, selecting specific goals and making plans, using CBT strategies to deal with obstacles, strengthening cognitive reappraisals when having new experiences – reviewing and consolidating lessons and encouraging constant changes An integrated cognitive-behavioral therapy with strength-based motivational approach intervention reduced gaming disorder symptoms and time spent gaming over a 6-month period by decreasing maladaptive gaming motivation and cognition. Serena M. King PhD | Powered Up | Module #3 Clinical Application  Background: Joel is a 13 year old boy. Used a cell phone early and his parents were seeing an increased rate of gaming duration over time, from 1 to two hours up to 6 to 8 hours a day. The gaming was impacting social life, academic performance sand the client presents with concerns about school and home life impacts.. This excessive gaming interfered with his school assignments, leading to a noticeable decline in his scholastic performance, which became the main concern for his parents. When attempts were made to limit or change his gaming time, he began to refuse to attend school. He exhibited irritability and argumentativeness when limits were imposed on his gaming activities. He began preferring time spent on gaming over other activities, leading to a lack of self-confidence Case Study: when interacting with peers and teachers. His social interactions with relatives also declined, and he became socially detached, eventually abandoning school to spend more time gaming. There was no past or family history of psychiatric illness. Joel, age 13 Assessment: The boy was assessed using the Internet Gaming Disorder Scale-Short Form (IGDS9-SF) and obtained a score of 31. During the interview, the boy revealed low self-esteem but reported preserved sleep and appetite. He mentioned that playing online games provided him with a sense of connection. Differential diagnoses of depression, anxiety, and attention deficit hyperactivity disorder (ADHD) were ruled out. A provisional diagnosis of IGD was made according to the DSM-5 criteria. Plan: Plan included a gradual reduction of gaming time, encouragement to explore other areas of interest and indoor activities, and providing a safe environment for the boy to express his feelings. Additionally, psychoeducation for the parents about IGD and strategies to improve their interaction with their child was provided. Adapted from the published case study- Sravanthi et al., 2024 Serena M. King PhD | Powered Up | Module #  1. Reduce the frequency and duration of gaming sessions. 2. Develop healthy coping mechanisms and alternative activities and ways of thinking using cognitive CBT goals restructuring 3. Modify behaviors by determining the antecedents of for Joel gaming and modifying precursors and reinforcers 4. Address any underlying mental health concerns via a similar treatment model. Serena M. King PhD | Powered Up | Module # 3  Cognitive Restructuring Replace negative thoughts with more balanced perspectives. Cognitive reframing - reduce gaming urges and cravings. Behavioral Therapy: restructure activities in ways that are not reinforcing to patterns of gaming Stimulus Control: CBT treatment Identify triggers for gaming and develop strategies to avoid or minimize exposure. components Create a daily schedule that includes time for gaming, schoolwork, hobbies, and social interactions. Reward Systems: for Joel Establish a reward system to reinforce positive behaviors and achievements outside of gaming. Set achievable goals and reward progress towards them. Social Skills Training: Develop effective communication and social skills. Practice assertiveness and conflict resolution techniques. Encourage participation in enjoyable activities that do not involve gaming Serena M. King PhD | Powered Up | Module #3 Up Next…Knowledge Check  References Delfabbro, P., & King, D. (2015). On Finding the C in CBT: The Challenges of Applying Gambling-Related Cognitive Approaches to Video-Gaming. Gambling Studies, 31, 315-329. https://doi.org/10.1007/s10899-013-9416-3 Kim, J., Lee, S., Lee, D., et al. (2022). Psychological treatments for excessive gaming: A systematic review and meta-analysis. Scientific Reports, 12, 20485. King, D., Delfabbro, P., & Griffiths, M. (2010). Cognitive Behavioral Therapy for Problematic Video Gamer Players: Conceptual Considerations and Practice Issues. Journal of Cybertherapy and Rehabilitation, 3(3). Lindenberg, K., Kindt, S., & Szász-Janocha, C. (2022). Effectiveness of Cognitive Behavioral Therapy-Based Intervention in Preventing Gaming Disorder and Unspecified Internet Use Disorder in Adolescents: A Cluster Randomized Clinical Trial. JAMA Network Open, 5(2), e2148995. doi: 10.1001/jamanetworkopen.2021.48995 Park, J. J., Booth, N., Bagot, K. L., & Rodda, S. N. (2020). A brief internet-delivered intervention for the reduction of gaming-related harm: A feasibility study. Computers in Human Behavior Reports, 2. Sravanthi, K., Nihal, N. G., Raju, N. N., & Mane, S. (2024). A Case Report of Internet Gaming Disorder Treated With Bupropion and Cognitive Behavioral Therapy. Cureus, 16(6), e63013. doi: 10.7759/cureus.63013 Young, K. S. (2013). Treatment outcomes using CBT-IA with Internet-addicted patients. Journal of Behavioral Addictions, 2(4), 209-215. doi: 10.1556/JBA.2.2013.4.3 Serena M. King PhD | Powered Up | Module #3