Hooked on the Web: Help Is on the Way

By SARAH KERSHAW

REDMOND, Wash. -- The waiting room for Hilarie Cash's practice has the look and feel of many a therapist's office, with soothing classical music, paintings of gentle swans and colorful flowers and on the bookshelves stacks of brochures on how to get help.

But along with her patients, Dr. Cash, who runs Internet/Computer Addiction Services here in the city that is home to Microsoft, is a pioneer in a growing niche in mental health care and addiction recovery.

The patients, including Mike, 34, are what Dr. Cash and other mental health professionals call onlineaholics. They even have a diagnosis: Internet addiction disorder.

These specialists estimate that 6 percent to 10 percent of the approximately 189 million Internet users in this country have a dependency that can be as destructive as alcoholism and drug addiction, and they are rushing to treat it. Yet some in the field remain skeptical that heavy use of the Internet qualifies as a legitimate addiction, and one academic expert called it a fad illness.

Skeptics argue that even obsessive Internet use does not exact the same toll on health or family life as conventionally recognized addictions. But, mental health professionals who support the diagnosis of Internet addiction say, a majority of obsessive users are online to further addictions to gambling or pornography or have become much more dependent on those vices because of their prevalence on the Internet.

But other users have a broader dependency and spend hours online each day, surfing the Web, trading stocks, instant messaging or blogging, and a fast-rising number are becoming addicted to Internet video games.

Dr. Cash and other professionals say that people who abuse the Internet are typically struggling with other problems, like depression and anxiety. But, they say, the Internet's omnipresent offer of escape from reality, affordability, accessibility and opportunity for anonymity can also lure otherwise healthy people into an addiction.

Dr. Cash's patient Mike, who was granted anonymity to protect his privacy, was at high risk for an Internet addiction, having battled alcohol and drug abuse and depression. On a list of 15 symptoms of Internet addiction used for diagnosis by Internet/Computer Addiction Services, Mike, who is unemployed and living with his mother, checked off 13, including intense cravings for the computer, lying about how much time he spends online, withdrawing from hobbies and social interactions, back pain and weight gain.

A growing number of therapists and inpatient rehabilitation centers are often treating Web addicts with the same approaches, including 12-step programs, used to treat chemical addictions.

Because the condition is not recognized in psychiatry as a disorder, insurance companies do not reimburse for treatment. So patients either pay out of pocket, or therapists and treatment centers bill for other afflictions, including the nonspecific impulse control disorder.

There is at least one inpatient program, at Proctor Hospital in Peoria, Ill., which admits patients to recover from obsessive computer use. Experts there said they see similar signs of withdrawal in those patients as in alcoholics or drug addicts, including profuse sweating, severe anxiety and paranoid symptoms.

And the prevalence of other technologies - like BlackBerry wireless e-mail devices, sometimes called CrackBerries because they are considered so addictive; the Treo cellphone-organizer ; and text messaging - has created a more generalized technology addiction, said Rick Zehr, the vice president of addiction and behavioral services at Proctor Hospital.

The hospital's treatment program places all its clients together for group therapy and other recovery work, whether the addiction is to cocaine or the computer, Mr. Zehr said.

"I can't imagine it's going to go away," he said of technology and Internet addiction. "I can only imagine it's going to continue to become more and more prevalent."

There are family therapy programs for Internet addicts, and interventionists who specialize in confronting computer addicts.

Among the programs offered by the Center for Online Addiction in Bradford, Pa., founded in 1994 by Dr. Kimberly S. Young, a leading researcher in Internet addiction, are cyberwidow support groups for the spouses of those having online affairs, treatment for addiction to eBay and intense behavioral counseling - in person, by telephone and online - to help clients get Web sober.

Another leading expert in the field is Dr. Maressa Hecht Orzack, the director of the Computer Addiction Study Center at McLean Hospital in Belmont, Mass., and an assistant professor at Harvard Medical School. She opened a clinic for Internet addicts at the hospital in 1996, when, she said, "everybody thought I was crazy."

Dr. Orzack said she got the idea after she discovered she had become addicted to computer solitaire, procrastinating and losing sleep and time with her family.

When she started the clinic, she saw two patients a week at most. Now she sees dozens and receives five or six calls daily from those seeking treatment elsewhere in the country. More and more of those calls, she said, are coming from people concerned about family members addicted to Internet video games like EverQuest, Doom 3 and World of Warcraft.

Still, there is little hard science available on Internet addiction.

"I think using the Internet in certain ways can be quite absorbing, but I don't know that it's any different from an addiction to playing the violin and bowling," said Sara Kiesler, professor of computer science and human-computer interaction at Carnegie Mellon University. "There is absolutely no evidence that spending time online, exchanging e-mail with family and friends, is the least bit harmful. We know that people who are depressed or anxious are likely to go online for escape and that doing so helps them."

It was Professor Kiesler who called Internet addiction a fad illness. In her view, she said, television addiction is worse. She added that she was completing a study of heavy Internet users, which showed the majority had sharply reduced their time on the computer over the course of a year, indicating that even problematic use was self-corrective.

She said calling it an addiction "demeans really serious illnesses, which are things like addiction to gambling, where you steal your family's money to pay for your gambling debts, drug addictions, cigarette addictions." She added, "These are physiological addictions."

But Dr. Cash, who began treating Internet addicts 10 years ago, said that Internet addiction was a potentially serious illness. She said she had treated suicidal patients who had lost jobs and whose marriages had been destroyed because of their addictions.

She said she was seeing more patients like Mike, who acknowledges struggling with an addiction to online pornography but who also said he was obsessed with logging on to the Internet for other reasons. He said that he became obsessed with using the Internet during the 2000 presidential election and that now he feels anxious if he does not check several Web sites, mostly news and sports sites, daily.

"I'm still wrestling with the idea that it's a problem because I like it so much," Mike said.

Three hours straight on the Internet, he said, is a minor dose. The Internet seemed to satisfy "whatever urge crosses my head."

Several counselors and other experts said time spent on the computer was not important in diagnosing an addiction to the Internet. The question, they say, is whether Internet use is causing serious problems, including the loss of a job, marital difficulties, depression, isolation and anxiety, and still the user cannot stop.

"The line is drawn with Internet addiction," said Mr. Zehr of Proctor Hospital, "when I'm no longer controlling my Internet use. It's controlling me." Dr. Cash and other therapists say they are seeing a growing number of teenagers and young adults as patients, who grew up spending hours on the computer, playing games and sending instant messages. These patients appear to have significant developmental problems, including attention deficit disorder and a lack of social skills.

A report released during the summer by the Pew Internet and American Life Project found that teenagers did spend an increasing amount of time online: 51 percent of teenage Internet users are online daily, up from 42 percent in 2000. But the report did not find a withering of social skills. Most teenagers "maintain robust networks of friends," it noted.

Some therapists and Internet addiction treatment centers offer online counseling, including at least one 12-step program for video game addicts, which is controversial. Critics say that although it may be a way to catch the attention of someone who needs face-to-face treatment, it is akin to treating an alcoholic in a brewery, mostly because Internet addicts need to break the cycle of living in cyberspace.

A crucial difference between treating alcoholics and drug addicts, however, is that total abstinence is usually recommended for recovery from substance abuse, whereas moderate and manageable use is the goal for behavioral addictions.

Sierra Tucson in Arizona, a psychiatric hospital and behavioral health center, which treats substance and behavioral addictions, has begun admitting a rising number of Internet addicts, said Gina Ewing, its intake manager. Ms. Ewing said that when such a client left treatment, the center's counselors helped plan ways to reduce time on the computer or asked those who did not need to use the Web for work to step away from the computer entirely.

Ms. Ewing said the Tucson center encouraged its Internet-addicted clients when they left treatment to attend open meetings of Alcoholics Anonymous or Narcotics Anonymous, which are not restricted to alcoholics and drug addicts, and simply to listen. Or perhaps, if they find others struggling with the same problem, and if those at the meeting are amenable, they might be able to participate.

"It's breaking new ground," Ms. Ewing said. "But an addiction is an addiction."