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Int J Child Adolesc Health 2013;6(4):475-486 ISSN: 1939-5930 © Nova Science Publishers, Inc.

Development of an integrated intervention model for Internet addiction in Hong Kong

Daniel TL Shek, PhD, FHKPS, BBS, JP1,2,3,4,5 and Hildie Leung1 1Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, PR China 2 Centre for Innovative Programmes for Adolescents and Families Public Policy Research Institute, The Hong Kong Polytechnic University, Hong Kong, PR China 3Kiang Wu Nursing College of Macau, Macau, PR China 4Department of Social Work, East China Normal University, Shanghai, PR China 5Division of Adolescent Medicine, Department of Pediatrics, Kentucky Children’s Hospital, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America

 Correspondence: Professor Daniel TL Shek, PhD, FHKPS,

BBS, JP, Chair Professor of Applied Social Sciences, Faculty of Health and Social Sciences, Department of Applied Social Sciences, The Hong Kong Polytechnic University, Room HJ407, Core H, Hunghom, Hong Kong. E-mail: daniel.shek@ polyu.edu.hk

Abstract

In response to the severe lack of indigenously developed preventive and counseling services for young people displaying Internet addiction problem, the Community Chest of Hong Kong funded a pioneering project entitled “Youngster Internet addiction prevention and counseling service”. Besides provision of preventive services at the community, school, family and individual levels, individual-based and family-based counseling services were developed for young people displaying Internet addiction problem. In this paper, the major features of the counseling model are outlined, including emphases on controlled and healthy use of the Internet, understanding the change process in adolescents with Internet addiction problem, use of motivational interview methods, adoption of a family perspective, multi-level counseling at the individual, peer and family levels, and the use of both case and group approaches. The process of intervention in this counseling model is also described. Evaluation findings provide support for this integrated intervention model.

Keywords: Internet addiction; family intervention; individual counseling; motivational interviewing

Introduction

Despite potential educational and entertainment value of the Internet, its attractive nature may create addiction in young people. In fact, there are research findings showing that problematic or pathological use of the Internet adversely affects the physical, psychological, social, and spiritual health of adolescents (1,2). There are also research findings showing that problem use of the Internet is quite prevalent in young people in the West (3,4) and the Asian contexts (5,6). For instance, according to a report on youth Internet addiction disorder published in 2009, approximately 14.3% of adolescents in China aged between 13-17 years and 15.6% of those aged between 18-23 years who had access to computers

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suffered from Internet addiction (7). Studies conducted in Taiwan found that 18.8% of high school students (8) and 17.9% of senior high school students (9) were classified as being addicted to the Internet.

With specific reference to Hong Kong, Leung (10) concluded that 37.9% of the respondents were identified as Internet addicts. In another study (11), it was estimated that roughly 20% of the respondents could be classified as Internet addicted. In a longitudinal study of Internet addiction in students in Hong Kong, findings showed that Internet addiction is a common risk behavior in secondary school students. Using Young’s 10-item Internet Addiction Test, roughly one-fourth of Secondary 1 and Secondary 2 students could be classified as having Internet addiction. Besides, both psychosocial and familial factors have been associated with Internet addiction among youths (12-14). Specifically, Shek and Lu (12) found that the possession of positive and clear identity and general positive youth development predicted a lower probability of Internet addiction. Furthermore, adolescents with divorced parents were more likely to engage in pathological use of the Internet; perceived parental rearing behaviors that were lacking emotional warmth, rejecting, and punitive, were also associated with Internet addiction in adolescents (15).

In contrast to the growing Internet addiction in the global contexts, related work on intervention is scattered and was conducted in unsystematic manners (16,17). Furthermore, there is very little published work on successful intervention models in the Chinese contexts. Intervention models in the Chinese contexts are important because there is evidence showing that Chinese people displayed more pathological gambling behavior than did non-Chinese people (18,19). The widespread use of opium in China before the Opium War also suggests that we need Chinese models on addiction.

With the funding from the Community Chest of Hong Kong, a pilot project entitled “Youngster Internet addiction prevention and counseling service” was launched by the Jockey Club Wah Ming Lutheran Integrated Service Centre, Hong Kong Lutheran Social Service, and Lutheran Church-Hong Kong Synod (LC-HKS). The major objectives of this pilot project were: a) to provide preventive education programs at the community, school, family, and individual levels; and b) to conduct a pilot project on

individual- and family-based counseling services for young people who have displayed Internet addictive behavior. In this paper, the basic features of the intervention model and the process of intervention are outlined.

Features of the intervention model

As there are few validated intervention models for Internet addiction in the global and local contexts, the Research Team attempted to pull together intervention strategies and techniques together in the fields of substance abuse, family counseling, and peer support group. Essentially, the intervention model adopted in this pilot project has the following features:

1. Emphasis on controlled and healthy use of the Internet: Instead of proposing complete abstinence of Internet use, it is argued that Internet use is intrinsically neutral. As such, controlled and healthy use was regarded as the desired outcome. This principle can also facilitate the involvement of the adolescent client in the counseling process. 2. Understanding the change process in adolescents with Internet addiction behavior: In the stages of change model (20, 21), there are several stages in the process of change, including pre-contemplation, contemplation, determination, action, maintenance, and relapse. In the pre- contemplation stage, the client may not think that his/her Internet use behavior is problematic and he/she does not consider changing his/her Internet use behavior. In the contemplation stage, the person starts to realize that his/her Internet use behavior is problematic and considers the possibility of changing. However, the consideration is ambivalent in nature. In the determination stage, the person decides to change his/her Internet use behavior. In the action stage, the person starts to decrease his/her online time. The person is successful in changing if he/she can maintain the changed Internet use behavior. Otherwise, relapse occurs and he/she might go through the stages of change again.

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This model was used in the present context to understand the needs of adolescents with Internet addiction problem and their family members. In the

intervention model, counseling tasks in relation to these different stages of change were devised. The details are described in table 1 and table 2.

Table 1. Individual-Based and Family-Based Counseling Tasks in the First Few Stages of the Change Process

Stages of Change

Individual-Based Counseling Family-Based Counseling

Pre- Contemplation

 Making connection by expressing empathy.  Understanding the daily functioning, thinking,

and feeling with respect to different areas such as school, peer and family contexts.

 Understanding the needs and concerns of the client.

 Understanding the positive and negative aspects of Internet use.

 Developing discrepancy between what one wants and the current Internet use behavior.

 Helping parents to handle emotions aroused by their children’s Internet addictive behavior.

 Helping parents to understand their children’s needs and other problems behind the Internet addictive behavior.

 Identifying the interaction patterns which maintain the Internet addictive behavior.

Contemplation  Constructing decisional balance about change and no change which is in favor of changing current Internet use behavior.

 Strengthening self-efficacy so as to enhance the possibility of change.

Determination  Developing plans for changing Internet use behavior, not just an Internet use time table, but also a short-term plan about study or career. Different resources, such as the Youth Pre- Employment Training Program might be introduced whenever appropriate.

 Engaging the client to join peer support groups, interest classes, or voluntary services.

 Facilitating direct and congruent parent-child communication, thus improving their mutual understanding and relationships.

 Breaking the circular interaction patterns which maintain the Internet addictive behavior.

 Developing and strengthening interaction patterns of dealing with the conflict about Internet use, which in turn promote healthy Internet use habits.

Action  Strengthening problem solving skills for handling the difficulties in carrying out the action plan.

 Providing support to develop self-efficacy.  Expressing empathy for those facing

difficulties during the changing process.

Table 2. Individual-Based and Family-Based Counseling Tasks in the Maintenance and Relapse Stages

Stages of Change

Individual-Based Counseling Family-Based Counseling

Maintenance  Identifying and handling the factors associated with the risk of relapse.

 Strengthening social support network.

 Maintaining support and encouragement for developing healthy Internet use habits.

Relapse

 Providing supportive environment for learning from relapse and motivating to re-cycle through the stages of change.

 Helping parents to handle emotions caused by relapse.

 Identifying the improved interaction patterns and those still needing to be improved.

 Helping parents to maintain supportive family environment and motivating them not to give up.

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3. Utilization of motivational interviewing model: Motivational interviewing is a directive, client- centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence (22-24). It assumes that the responsibility and capability for change are within the client. Five basic principles are intrinsic to motivational interviewing. These include: a) expression of empathy via reflective listening to convey understanding of the client’s thinking and feeling; b) pointing out discrepancy between the client’s current behavior and future goals; c) avoid unnecessary arguments which evoke resistance to change; d) resistance and ambivalence are viewed as normal and are explored openly; e) support self-efficacy by building the client’s confidence that he/ she can make a change. There are research findings supporting the effectiveness of motivational interviewing in the context of addiction (reference?). 4. Adoption of the family perspective: Instead of simply blaming adolescents for addictive behavior, it is noteworthy that such behavior may be a result of different ecological factors, particularly family factors (25,26). According to the family perspective, an adolescent with Internet addictive behavior represents a symptom of a dysfunction within a family rather than the individual’s maladjustment. For example, the child’s Internet addictive behavior might be a symptom of the marital and parenting conflicts amongst the parents. Furthermore, it is proposed that change in an individual member of the family system would cause change in other family members as well as the whole family system. For example, a father changing his way in dealing with the son’s Internet addictive behavior can improve his relation and communication with the son, and the son might react by becoming more willing to cooperate when the father disciplines his Internet use behavior. Indeed studies have found Internet-specific parenting practices, such as the increase in quality of parent-child communication on the use of Internet (27), and the maintenance of appropriate parental norms regarding Internet use (28), to be negatively

associated with pathological Internet use among adolescents.

In short, Internet addiction often occurs in the family context which results in serious conflicts between the adolescents and their parents. As there are family theories and research suggesting that family factors are etiological as well as therapeutic factors underlying addiction problems, family-based counseling is considered important in this pilot project. The systemic view, which is the foundation of different family therapies, was employed as the theoretical backdrop of family-based counseling utilized in this project. 51. Multi-level counseling model: Based on the preceding discussion, an intervention model incorporating the following elements was developed:  Individual counseling component: The

intervention model is an integration of the process of change model and motivation interviewing techniques. It is proposed that different counseling elements are intrinsic to different stages of change (see Table 1 and Table 2). The techniques intrinsic to the individual-based counseling model can be seen in Table 3.

 Family counseling component: Based on the systemic and family perspectives, it is argued that intervention at the family level such as enhancement of family functioning and improvement of parenting skills are important. The related family counseling tasks in relation to different stages can be seen in Table 1 and Table 2. The techniques intrinsic to the family-based counseling model can be seen in Table 4.

 Peer support component: Besides intervention at the individual and family levels, peer relation is also important for adolescents. In the context of addiction, peer influence has been found to be an important factor for substance abuse (29). At the same time, peer support is also very important for the maintenance of healthy Internet use habit. As such, different supportive activities including volunteer groups and interest

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classes were organized in this pilot project. The objectives of these activities included the improvement of social skills, establishment of supportive social network, realization of

one’s strengths and potentials, and promotion of healthy social engagement amongst the program participants.

Table 3. Summary of Individual-Based Counseling Techniques

Motivational Interviewing Elicitation of Self-Motivational Statements  Self-motivational statements regarding adolescent clients’ talk of concerns about online behavior, desire, reasons, ability and commitment for change were elicited.  Such statements should be elicited from the adolescent clients rather than being told or imposed. Handling Resistance  Avoided argumentation which elicited resistance.  Reflection which exaggerated the adolescent clients’ resistance of changing the Internet addictive behavior might induce the adolescent clients to say the opposite.  Double-sided reflection highlighted the ambivalence experienced, with the emphasis that the adolescent clients had the responsibility to choose whether they wanted to change. Good Things and Less Good Things  Good things about going online were explored together with the adolescent clients, followed by the less good things about going online.  Adolescent clients tended to be more willing to discuss the “less good things” after the “good things”. Both sides had been discussed thoroughly and summarized appropriately. Decisional Balance  The discussion was similar to “good things” and “less good things” except that it focused on future behavior.  The pros and cons of changing the Internet addictive behavior were identified and compared with the pros and cons of not changing the behavior.  Emphasized that adolescent clients could make differences and they could choose to live in the way they really wanted. Values Exploration  Encouraged the adolescent clients to rank different value statements.  The meaning of value statements, discrepancies between values and their current online behavior, and perceived barriers and opportunities of decreasing discrepancies were discussed.  This process helped the adolescent clients to evaluate whether their behavior fulfilled their short-term needs while violated the values they treasured in the long run. Discussion of the Stages of Change  The stages of change were explained and the adolescent clients were asked to determine their current stage.  The adolescent clients were also helped to review whether they experienced different stages of change in the past and what would cause them to move between different stages. OARS (Open-end questions, Affirmations, Reflective listening, and Summarization)  Basic techniques of motivational interviewing summarized by the acronym OARS (Open-end questions, Affirmations, Reflective listening, and Summarization) were also applied. Other Individual-Based Counseling Techniques Feedback on Online Behavior  Objective assessment on Internet addiction was conducted and the results were discussed. Construction of Personal Inventory  A list of activities that had been neglected after the adolescent clients’ establishment of Internet addictive behavior was constructed.  This technique helped the adolescent clients to evaluate the negative impacts of deterring the engagement in interesting or important activities due to the Internet addiction behavior. Construction of Behavioral Contract  Set time limit on using the Internet.  Explored alternatives which could occupy the free time after spending less time online.  Difficulties of implementation and the related solutions were discussed. Development of Career Plan  Developed career plan and related action plan such as taking courses or applying jobs.  This aspect was essential for those who had left school and were unemployed, as they had a lot of free time to stay online if the non-engaged situation persisted.

Note: Techniques are based on Miller (1995) and Treasure (2004).

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Table 4. Summary of Family-Based Counseling Techniques

Family-Based Counseling Reframing the Symptoms of Internet Addiction  The mutual influences of family members’ interactions were emphasized in the counseling process. The interaction patterns regarding the adolescent clients’ Internet addictive behavior (such as inconsistent parenting) were examined to help the parents identify their influences.  To broaden parents’ understanding of their children’s online behaviors, Internet addictive behavior could also be reframed as their children’s attempt to fulfill their interpersonal needs through online activities. Dealing with Unbalanced Power  In some cases, the family power structure was upside down as children’s superior computer knowledge might cause their parents to feel powerless in disciplining their children’s Internet use behavior. Support was given to the parents for performing appropriate parenting roles.  External stoppers such as parent-child service plan provided by some Internet service providers, which enabled the parents to control their children’s online time, could be introduced as a way to empower the parents. Resolution of Conflicts  As there were continuous daily conflicts related to the Internet use behavior of the adolescent clients, such as when to go offline and the adolescent clients staying online during meal time, helping the parents and the adolescent clients to resolve the conflicts was a very important task.  Skills for handling the emotions aroused by the conflicts were introduced and discussed with the parents and the adolescent clients.  Facilitation of congruent communication which considered the self, others, and the context in parent-child interaction was important. This process attempted to find the solution which was accepted by both the parents and the adolescent clients. Discussion of the Stages of Change  The stages of change were explained and the parents were asked to identify which stage of change best described their children’s current situation.  The model helped to reframe the idea of “my child did not want to change” into “my child was in the pre-contemplation stage, which was the first step of change”. It helped the parents to understand that change was a progressive process instead of simplifying it as a dichotomy of “change” or and “not change”.  Parents were helped to identify appropriate actions to motivate their children in the different stages of change.

Note: Techniques are based on Hanna and Brown (1995).

62. Utilization of case work and group work: As peer relations are very important in adolescent development, peer support group approach was used as a supplement to the casework approach. With the use of group dynamics, mutual support, and modeling opportunities, group members can learn from each other. With group atmosphere characterized by empathy, sincerity, and respect, group members serve not only to help them establish positive self-image, but also act as role models for others. Peer support group can also help group members establish social support network, which would help them maintain healthy Internet use habits.

In short, through the use of case work and group

work, the proposed intervention focused on enhancing adolescents’ motivation to change, changing the adolescents’ cognitions and Internet addictive behavior, changing the dysfunctional familial interactive patterns, and eventually helping the adolescents to develop healthy Internet use habits.

Clients in the intervention program

A total of 59 cases participated in the project. Generally speaking, cases that were identified as Internet addicts by one of the assessment tools described in the evaluation report (30,31) were eligible for receiving the service. However, there was one case that did not meet the above assessment criteria. As he almost met the diagnostic criteria of Young’s 10-item questionnaire (i.e., he responded “Yes” to 3 of the questions) and he desperately wanted to be helped, service was provided to him. Regarding the gender of the program participants, 58 were males and 1 was female. Most of them were early adolescents (aged 11- to 15 years; N=29) and late adolescents (aged 16-18 years; N=27), with 3 program participants aged over 18 years. The educational background of the program participants was as follows: primary education (N=7); Secondary 1 to Secondary 3 (N=33); Secondary 4 to Secondary 5 (N=18); Secondary 6 or/and above (N=1). Different sources of referral for the cases were identified,

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including school social workers (N=27), parents (N=22), teachers (N=5), non-school social workers (N=4), and siblings (N=1).

The intervention process

Stage 1 (Initial Contact and Establishment of Relationship)

For the cases referred by social workers and teachers, relevant information including adolescent clients’ Internet use habits, impacts of their Internet use habits on adolescent clients’ daily social functioning, methods that had been used to help adolescent clients, and the effects of those methods was collected. The referrers were also informed that we would intake the cases only if the adolescents met the assessment criteria.

For most of the cases, it was the parents who sought help (either by themselves or via school social workers) for their children’s Internet addiction problem. They usually felt helpless and wanted to depend on the worker. In the initial contact, their involvements in the counseling process were emphasized and the stages of change were also explained to them, such that they would be aware that change was a process that needed time to take place. In addition, the parents were asked about how they dealt with the problem and how the parents and their children reacted to each other’s reactions.

In the initial contacts with the adolescents, information in different areas, including which online games the adolescent clients played, time spent on the Internet, adolescent clients’ interests and hobbies, and initial impression about the referral was collected. Other relevant information was also collected so as to determine where (e.g., school or home), when (e.g., weekday after school or Sunday afternoon), and how (e.g., individual interview, joint interview together with parents or phone contact) to render the service to them in the later stage of the counseling process. As the adolescent clients were often at the stage of pre- contemplation or contemplation, they were not really motivated to see the worker. As such, acceptance and empathy were crucial. It was important to make connections with the adolescent clients by showing the interest in “understanding” their thinking and

feelings rather than “solving” the Internet addiction problem.

Stage 2 (Intervention involving individual- based counseling, family-based counseling and peer support group)

After establishing working relationships with the adolescent client, the evaluation questionnaire containing the Internet addiction assessment tools was administered. Except the one case mentioned above, if the adolescent client met the criteria in one of the assessment tools, he/she would receive both individual-based counseling and family-based counseling and he/she would be invited to join the peer support group. The major goal of the intervention would be to help the adolescent client to develop healthy Internet use habit (i.e., a decrease in Internet addiction symptoms).

Individual-based counselling

The adolescent clients were often at the stage of pre- contemplation or contemplation and they were unmotivated to see the worker. Based on the implementation experiences, three categories of adolescent clients with Internet addiction problems were identified.

 For the first category, the adolescent clients

did not have specific goals and they felt their lives were boring. They spent a lot of time online as they could not find other interesting things for them to kill time. It was very difficult to motivate them to change their Internet use habits as they did not see that there would be any serious negative consequences. It was very difficult to motivate them to move from the pre- contemplation stage to contemplation and determination stages by finding out their needs and desire so as to narrow the discrepancy between what they wanted and what they had to do. It was a good way to strengthen relationships with them through activities and helped them to establish

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meaningful connections with peers. At the same time, it was crucial to facilitate the adolescent clients and their parents to improve the communication and mutual understanding so that they could handle the conflicts due to the adolescent clients’ Internet addictive behavior in a better way.

 The second category included adolescent clients with emotional problems who used Internet as a way to escape from the depressive mood. As long as they could better handle their emotions, they would less depend on the Internet and were motivated to change. They could also develop their own action plans and reduced the time on the Internet. Thus, it was also essential for the parents to understand that their children concealed the emotional problems under the Internet addictive behavior. This did not only remove the stress which might intensify the children’s emotional problems and drove them to increase the Internet use for escaping, but also provided a supportive environment for the adolescent clients to handle their emotional problems. It should also be noted that in some cases, psychiatric intervention might be necessary.

 The last category included adolescent clients characterized by poor self-image. Basically, the lack of successful experience in daily life made them turn to seek gratification from the Internet by being absorbed in playing one or a few online games. They would spend a lot of time on the same online game or even buy some powerful weapons of the game, so that they could maintain a high status in the online game. They were trying to build successful and competent images in the online games. Thus, it was essential to help them establish positive self-images through doing voluntary works, which could provide the opportunity for them to gain successful experience and realize their own strengths. Parental support and compliments were also important for creating a positive cycle for the adolescent clients to start establishing healthy Internet use habits.

Family-based counseling

Where appropriate, conjoint family interviews and family counseling sessions were carried out to facilitate the parents and their adolescent children to understand their mutual expectations, to improve the parent-adolescent relationships, and to foster healthy parent-adolescent interactions.

Peer support group

Originally, it was planned to organize groups for both the adolescent clients and their parents separately. However, a lot of difficulties were encountered. First, as the adolescent clients lived in different districts, such as Tseung Kwan O, Shatin, and Sheung Shui, they were not motivated to travel a long distance to join the group. Second, as many parents had very long working hours, it was very difficult to arrange suitable time schedules for forming groups with enough number of group members. As a result, only a support group for adolescent clients was organized. For adolescent clients who had not joined the support group, the workers would motivate them to be volunteers or join the interest classes so as to promote healthy social engagement, and to realize their strengths and potentials. Eventually, nine adolescents became volunteers or joined the interest classes.

Because adolescents with Internet addictive behavior displayed problems of loneliness and weak social networks, supportive networks for them were important. As such, peer support group was designed with the following objectives:

1. To help group members to recognize their

own strengths and establish positive self- images.

2. To help group members to experience how to honestly face themselves and other people, so as to establish friendship with others.

3. To help group members to establish mutual respect, support, and caring relationships.

To avoid labeling effect, the support group took

the form of a volunteer group. To ensure homogeneity of the group, members were at the determination stage (i.e., they had decided to improve their Internet using

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behaviors) and the group size was small with no more than eight members. However, as it was difficult to recruit suitable participants who would commit to the group and were at the similar stage of change when the group was scheduled to start, the group size turned out to be smaller with five members only.

Besides, strong emphases on interaction amongst members and mutual sharing and caring were made. The worker was expected to act as a role model and demonstrate congruence, respect, and care in running the group. On the other hand, members were expected to have strong commitment and positive expectations about themselves. Broadly speaking, the objectives of each session in the peer support group are as follows:

 First session: Knowing each other;

establishing group norms; sharing individuals’ expectations;

 Second and third sessions: Team building; recognizing one’s strengths;

 Fourth and fifth sessions: Self-exploration; sharing with others;

 Sixth session: Expressing mutual support and encouragement; consolidation of the group experience.

The main themes and activities for each session

in the peer support group are listed in Table 5.

Stage 3 (Termination and follow up)

When the adolescent clients successfully established healthy Internet use habits or the families agreed that they were able to handle the children’s Internet use problem by themselves, changes in the adolescent clients’ Internet use habits and the family relationships were systematically evaluated.

Table 5. Main Themes and Activities for Each Session in the Peer Support Group

Session Main Themes and Activities 1 Brief introduction: The worker welcomed group members, introduced the group’s objectives, and highlighted the

importance of keeping the commitment to join the group. Ice breaking: Played 2 ice breaking games. Knowing each other: The worker and members drew an icon, and wrote down 3 characteristics of the icon which could represent them, and then shared. Establishing group norms: Forming pairs. Each pairs brainstormed 3 group norms, which they thought were most important, and represented those norms in actions. Other members guessed the meanings of those actions. Sharing expectations: Members re-drew and shared their icons by adding some changes to the icons to represent their expected changes when the group ended.

2 & 3 Team building: Played 2 team building games. In debriefing, the worker facilitated members to recognize others’ contribution in completing the tasks. Finally, the worker summarized the contribution with the following “contribution cards”: The picture of a brain: having some creative ideas. The picture of eyes: having insight on formulating workable action plans. The picture of ears: willing to listen and accept different opinions. The picture of a mouth: willing to discuss and share opinions with others. The picture of a heart: caring about others feelings and safety. The picture of hands: actively taking part in the tasks and trying different methods. The picture of legs: being supportive and encouraging when facing difficulties. Recognizing own strengths: Assigned 4 team tasks. After completing each team task, two members were selected. Other members chose “contribution cards” to represent those two members and explained the reasons for their choices. Besides, the worker secretly placed the “contribution cards” in the individual envelopes for all members to recognize their contribution in the task. After completing all the four team tasks, the worker displayed the “contribution cards” in each envelope openly for the members to discuss who should get which set of “contribution cards”. It was common for the members to have different opinions with the worker, and it was demonstrated that they observed something not noticed by the worker.

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Table 5. (Continued)

Session Main Themes & Activities Finally, members chose one “contribution card” for themselves and shared an experience during which they

demonstrated similar performance in their daily life. 4 & 5 Self-exploration and Sharing with others:

Members took four instant photos for facial expressions which represented the feelings of “happy”, “angry”, “afraid”, and “sad”. Then they pasted their photos on an A3 worksheet, which was divided into four parts. In each part, they pasted one photo and then wrote down the most unforgettable event related to the particular feeling. After completion of the four parts, members shared with others about those events related to the feelings of “happy”, “angry”, “afraid” and “sad”, why those events were so unforgettable, and why those events elicited those feelings.

6 Expressing mutual support and encouragement: A birthday party was organized for members whose birthdays were near. They were encouraged to organize birthday parties for other members in the future. Information facilitating future contact (i.e., MSN or email accounts) among members was exchanged for maintaining support after the group ended. Consolidation of the group experience: Members’ feelings and thoughts about the group were discussed. The changes among members were explored. Based on the group experience, future development of the group, such as the possibility of continuing the group, commitment of members, and the major goal of the group that should be continued, was also discussed. Evaluation: Members filled in the evaluation form, commented and discussed what they liked and disliked about the group.

Table 6. Condensed Case Illustration of Individual-Based and Family-Based Counseling

Case Background Yan was a Secondary 4 student of a Band 1 secondary school. Her parents divorced when she was in Primary 6. She was the only daughter and currently living with her mother. During her primary school education, she always obtained the first place in examinations. However, she started spending a lot of time online during her summer holiday in Secondary 1. Her school performance deteriorated and she barely got promoted to Secondary 4 in the same school. In addition, there were a lot of conflicts with her mother regarding her Internet use behavior. The Intervention Process Initial Contact and Assessment (About three months, with interviews every two weeks) A. Individual-based counseling with Yan and her mother while focusing on Yan  Expressing empathy and setting goal.  Understanding Yan’s daily functioning, thinking, and feeling in different areas.  Understanding the needs and concerns of Yan.  Helping Yan to understand the positive and relatively less positive facts about the Internet.  Helping Yan’s mother to handle emotions aroused by Yan’s Internet addictive behavior. B. After gathering the basic information and preparing Yan and her mother, family-based counseling via joint interviews was conducted

 Facilitating Yan’s mother to understand Yan’s needs, as well as other problems behind the Internet addictive behavior.  Identifying the interaction patterns which might maintain the addictive behavior of Yan. Intervention (About nine months, with interviews every month as stable working relationships had been established) A. Enhancement of parent-child interaction through joint interviews  Facilitating direct and congruent parent-child communication.  Breaking the circular interaction patterns which maintained the Internet addictive behavior.  Developing and strengthening interaction patterns for dealing with the conflicts about Internet use. B. Enhancement of Yan’s motivation to change  Developing discrepancy between what was wanted and the current Internet use behavior.  Strengthening self-efficacy so as to increase the possibility of change.  Developing plans for changing Internet use behavior, not just an Internet use timetable, but also a short-term plan about

her study or career.  Engaging her to join peer support groups, interest classes, or voluntary services.  Identifying and handling the factors associated with the risk of relapse.  Examining her social support network.

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C. Promotion of effective resolution of conflict  Encouraging use of “I” message and time out methods for avoiding over-emotional reactions.  Maintaining support and encouragement for healthy Internet use habits.  Helping Yan’s mother to handle emotions caused by relapse.  Identifying the improved interaction patterns and those still needing to be improved. Termination and Follow Up (About six months) As Yan’s Internet use behavior and the parent-child relationship stabilized, the case was systematically evaluated and terminated with the agreement of Yan and her mother. The worker then followed up by making phone contacts with Yan and her mother every month to keep track of Yan’s Internet use behavior and their relationship; this lasted for six months.

The cases would then be terminated and followed

up for six months. A summary of the intervention process and the intervention goals through a case illustration is shown in Table 6.

Evaluation of the intervention model

Several evaluation mechanisms were used to evaluate the effectiveness of the program. As far as objective outcome evaluation is concerned, a one-group pretest- posttest design with different outcome indicators (Internet addiction behavior, attitude to Internet addiction, parenting and psychological well-being) was employed (30). Results showed that Internet addiction behavior of the program participants significantly dropped after they joined the program and there were some changes in parenting after the intervention.

Regarding the findings based on subjective outcome evaluation, several observations can be highlighted from the study. First, all program participants agreed that the objectives of the program had been achieved via counseling and they felt much better as compared with the first time they received counseling. Second, all participants regarded the counseling as helpful. Third, most of the respondents (92.5%) agreed that they had learned how to deal with their own problems through counseling. Fourth, most of them agreed that they were more able to solve their own problems as compared with the first time they received counseling.

Qualitative analyses based on seven adolescents and three parent cases showed several observations. First, the impression about the program was basically positive. Second, the impression about the workers was also basically positive. Third, there were positive changes in Internet use amongst adolescent clients after receiving the service. Fourth, there were positive

changes in family relationships after receiving the service. Fifth, there were positive interpersonal relationship and cognitive changes in the informants after receiving the service. Sixth, several causes of change in the informants were identified (31).

Taken as a whole, the initial evaluation findings are very positive and they suggest the clinical utility of the integrated counseling model for young people with Internet addiction problem. Of course, the limitations of the existing evaluation of the integrated model should be realized. In future, randomized clinical trials and longitudinal evaluation studies should be conducted to examine the sustained effects of the program. In view of the lack of evidence-based addiction intervention programs in Hong Kong (32), the present study can be regarded as an interesting addition to the literature.

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Submitted: December 15, 2012. Revised: January 02,

2013. Accepted: January 24, 2013.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.