A Paradigm Shift from Addiction to Over-dependence in S. Korea

1. A Paradigm Shift from Addiction to Over-dependence in S. Korea Young-Sam, Koh(Ph. D) College of General Education, Tongmyong University, S.KOREA yeskoh7@gmail.com 2018. 10

2. 1. Ratio Rate of Smartphone Over-dependency by year(%) (High Risk Group) (Potential Risk Group) < Source: 2017Survey on Internet Over-dependency (National Information Society Agency) >

3. Rate of Smartphone Over-dependency byage(%) (High Risk Group) (Potential Risk Group) 60-69 Year olds Adult Kindergarten Youth < Source: 2017Survey on Internet Over-dependency (National Information Society Agency) >

4. 2. Analysis • Steady increase of Smartphone 0ver-dependency and concern • on new technology • Diffusion of over-dependency into all age groups • (Preschoolers  Adolescents, Youths Middle aged) • Special attention on over-dependency of social marginal •  Unemployed, Children of inter-race marriage, • People with disabilities

5. Adverse Impact • (Areas of Concern) Most of the concerns were about personality (psychological) issues (22.5%), followed by physical issues (19.3%), family relationship issues (15.9%), etc. • (Areas Requiring Help) Users chose personality (psychological) issues (22.5%) as the area that requires the most help in order to reduce the excessive use of smartphone, and this corresponds with the survey result on the areas of concern.

6. Psychological Problems • (Emotion) Users felt loneliness the most (36.4%), along with anxiety • (28.1%), depression (25.9%), and anger (24.2%) • (Personality) Users felt impulsivity (46.7%), sensitivity (36.8%), and dishonesty (30.9%) • (Perception) Users had a high tendency to relieve stress through the Internet (54.1%) and had a lower level of self-esteem • (Daily Experience) Users had stress (53.3%), lack of leisure activities (48.3%), and unsatisfactory lifestyle (44.9%)

7. Master Plan for Healthy SmartphoneInternet Use (2016~2018) 3. Policies : Master Plan [WISE]strategy • Development of government wide Master Plan to respond harms caused by Smartphone, Internet Over-dependency (by National Informatization Basic Act, article 30) • Make it every 3 years from 2010, and currently implementing of 3rd Master Plan Expansion of Healthy Use of Smartphone(Internet) Provision of Stable Treatment Service from counseling to recovery Improvement of Policy Impact via full cooperation Healthy use of Smartphone ·Internet from over dependency to proper utilization Improvement of Policy Outcome Capacity for Self Regulation Habit of Balanced Use Expertise on service delivery W Dependency Utilization Talk concert, Healthy use week , etc. Capacity Building Linked to Medical treatment Test of other disorders Cooperation with Hospital ※ Operation of healing woods (staying in woods), career experience program • Prevention • Counselling and Treatment • Capacity building & Best Case Identification • Cooperation & Policy Foundation Building Infants Toddler Youth Adults Elderly Best Cases Gov Awarding best idea or SW s for proper utilization of smartphone and Internet Wholesome Prevention Training via Kindergarten Use of audio/video tools Training via school activities Experience based Training Training via community program Provision of Adult Program Training via ICT program Special Program for elderly Require of new professionals Parental guide/role model Training to parents * Treatment of concurrent disorders such as depression, anxiety etc. Assigning new staffs Central , local gov. Policy Coordination Sustainable Recovery service Career counseling , Recode keeping of counseling High Quality Counseling Social Participation Re-counseling of recovered Activation of Self-supporting Community Advanced Counseling Global Social Campaign for Smart phone Rescue Movement Development of Counseling  Treatment Experts via retraining of counselors and teachers Change of curriculum into emphasizing ‘Healthy use via balance and self-regulation ' Strengthening compulsory prevention program Cooperation Network global cooperation (R & D , Campaign Civil I Community based counseling -education –welfare organizations Policy Support Integral Service and Recovery Outcome management Upgrading social Survey Cooperation management Strengthening R&D S Sustainable ICT Competence E Extensive Cooperation Governance

8. Policy change reflected in Master Plan • Currently 10 related Ministry are participating in responding new media environment, and followings are difference between 3rd and 1st/2nd master plans 1st Plan 2nd Plan 3st Plan ’16~ ’18 ’10~ ’12 ’13~ ’15 • Switch to smartphone based services • Internet, Smartphone • PC based Online game Media • Promotion of proper use based on balance and control • Capacity to control Internet use by life cycle • Decrease of Internet Addiction Rate Service Policy scope • Focusing Adolescents • Prevention, Counseling,and Medical treatment • Expansion to children • Prevention, Counseling, and Medical treatment Object • Expanding to all ages • Prevention, Counseling, Medical treatment, and Career development • Serviced by professional organization • Providers based services Service delivery • User centric customized services Service mechanism • Cooperation among Ministries • Cooperation bet. Governmen & Civic Sector • Cooperation among Ministries • - Same as past Cooperation • - Same as past • - Same as past Training of counselors • Re-training of existing • Counselors • Certificate

9. 4. Policies: Governance(Ministries) • Horizontal Governance of 10 related ministries (by pertinent laws and functional specialties) • Improving of policy effect via collaboration by Policy Coordination Committee • Coordinator for Smartphone, Internet Over-dependency- Master/Implementation Plan(Coordination Committee) • Prevention education, counselling , laws etc.- Annual survey on Internet over-dependency, Operation of Smart Healing Center • LegalizationTechnology, Guideline for Proper Use of Smartphone- Certificate for Internet Addiction Counselor MSIT • Prevention education of different age groups- Students, Teachers, Parents- Cyber crime prevention training program - Training for military personnel • Guideline for Safe Online Life - Healthy and proper use of smartphone MoE MoJ MoTIE MND Action for over-dependency of Smartphone, Internet • Service Design for Internet, Detox(R&D) • Treatment of high risk adolescents- Survey on adolescent’s online life - Operation of Youth Internet Dream Village - Counseling, Cooperation with hospitals • Parent’s guideline for Addiction prevention- Compulsory shut down (from 12 to 6 am) • Game literacy education - Family camp for healthy gaming • Prevention of mal-effect of gaming- Survey on game over-dependency, Operation of Game Obsession Healing Center • Guideline for prevention of game over-dependency- Voluntary shut down of gaming hours All related Ministries MoGEF MCST • Total Addiction Treatment Center including Internet addiction- Operation of Total Addiction Treatment Center KCC MoHW • Technical measure for preventing illegal contents-S/W like Cyber Safe Zone MoE : Ministry of Education MoHW : Ministry of Health and Welfare MoJ : Ministry of Justice MCST : Ministry of Culture, Sport and Tourism MND : Ministry of National Defense MoGEF : Ministry of Gender Equality and Family KCC : Korea Communications Commission MSIT: Ministry of Science, ICT MoTIE: Ministry of Trade, Industry, & Energy

10. Governance(bet. Public & Private) • Establishment of cooperation platform with special agencies including Ministries, education, media, and religious entities working for prevention and counselling service ▪ Internet Addiction Policy Council ▪National Information Society Agency • Korea Youth Counseling & Welfare Institute • Korea Creative Content Agency • Korean Institute for Healthy Family • MentalHealth Management Center Ministries ▪ All Offices of Education • National, public libraries • University Institutes • Korea Youth Work Agency • Korea Youth Shelter Association • Korean Medical Association • Korea Youth Association • Parent’s Union on Net • Cooperate Social Responsibility Agencies Cooperation bet public and private Education Mass media Religion ▪ Newspaper ▪ Broadcasters ▪ Internet Service Provider ▪ Korea Buddhism • Korea Catholic Church • The Communication of Churches in Korea

11. Governance(Cooperative system) 1st (Prevention) 2nd (Counseling) 3rd (Medical treatment) 4th (Recovery ) • After diagnosis of over-dependency, provision of full packaged service delivery for prevention, counselling, medical treatment, and after-care through cooperation with community based organizations Subject User, over-users Risk groups (Potential & high risk groups) Addict with other mental disorder Severe addict Recovered Goal Healthy daily life, awareness of addiction Early detection, Capacity to control Internet activity Effective treatment Rehabilitation, Balanced life Aptitude finding, Career development Actor Home, school, work place, community center Counseling center, Home Hospital Psychiatric clinics Home, school, work place, counseling center Medical diagnosis Drug treatment Hospitalization Counseling & management Providing social support ICTcareer coaching Providing alternative activities Activities Awareness of over-dependency Building social support Addiction prevention program Cultural activity Diagnosis of over-dependency & MH Providing Counseling Training for counselor Development of counseling program

12. 5. Paradigm Shift < ‘Addiction’ Paradigm(the past)> Tentative agreement on ‘Internet Addiction’ • Derived from Substance Addiction  status in which a user excessively connects on-line and shows profound social, mental, physical, financial problems in everyday life by it. There should be ‘tolerance’ and ‘withdrawal’ symptoms and a status in which many meaningful social and occupational activities are given up in order to use internet. * Duration should be more than 12 months • Framework “Act of National Informatization” (Article 3)  “The term "Internet addiction" means suffering, by users, of damage in physical, mental or social functions to the extent that it is not easily recoverable in their daily lives, due to excessive use of information communications services provided through information communications networks “

13. Past thoughts • Acquiring national budget: to get national budget, use strong word of ‘Addiction’ intentionally • Acquiring public interest: Prefer the journalistic not academic meaning of ‘Addiction’ to receive public attention • Possibility of complete cure(recovery) • Coexisting disease • Differences in purpose of counseling treatment • Different smartphone characteristics from internet game Lessons from experiences?

14. <‘Over-dependence’ Paradigm(the present)> Different approach from Disease model • Addiction •  disease model •  both of medical treatment and counseling • Over-dependence • Choice Theory, Competence build up Model •  both of counseling and life coaching

15. Choice Theory • Heyman(2009, 2013) Competence build up Model • T. Haegerich & P. Tolan(2008), N. Guerra & C. Bradshaw(2008) • D. McClelland(1973), Boyatzis(1982), L. Spencer & Spencer(1993), • R. Roe(2002), B. Crawford(2008), L. Salo-Lee(2006), N. Vazirani(2010) • “Maximising opportunities, Minimising risks”(EU)(Livingstone & • Haddon, 2009)

16. Smartphone Over-dependence Scale • Smartphone Over-dependence : Experience of serious consequences due to increase of salience and lose of self-control by over use of smartphone • Salience: A condition in which smartphone use becomes the most salient and important activity in one's daily life • Self-control Failure: A condition in which a person is not able to control her/himself on smartphone use in accordance with self-set goals • Serious Consequences: Experiences of negative consequences in physical, psychological, and social aspects due to problematic smartphone use

17. SmartphoneOver-dependence Scales(10~69years old)

18. Interpretation of the Scale

19. History of Changes in Problematic Internet Use Scales

20. Life counseling program for digital over-dependent youths • Paradigm Shift - Capacity to control the use of Internet, - Potential resources for the growth, - Counseling and coaching for life planning - labelling as disease - Counselling, treatment • Development of Measurement Tool • What is the motives to use Internet • Which sector of ICTfield do they have interested ? • What kinds of capacity do they have?

21. Internet Usage Needs Scale • 92 items(Junior and high school stu.)  • 48 items were selected through exploratory • factor analysis and facial validity verification • final scale consisted of ten subdomains(35items) • (1) Online relationship (2) New self experience • (3) Belonging and acceptance (4) Stress reduction • (5) Good self identification (6) Emotion expression • (7) Fun (8) Thought expression • (9) Accomplishment in game (10) Information gathering • - the scale had high reliability (Cronbach’s α = .944). • - Each of subscales also had high reliability • (Cronbach’s α = .744~.932). SPSS 22.0 • - ten-factor structure to be valid by model fit • (CFI .901, IFI .902, TLI .879, RMSEA .069), • and demonstrated correlations between • each of subscales and items.(using AMOS 22.0)

22. THANK YOU Young-Sam, Koh(Ph. D) yeskoh7@gmail.com 2018. 10

23. A psychotherapeutic Group Program for the Treatment of Internet Gaming Disorder and Internet Addiction in Adults and Adolescents Klaus Wölfling

24. Outpatient Clinic for Behavioral Addictions Mainz patient group: different forms of behavioral addiction  age range: 12-67 years! N = 523 gambling addiction (n = 63) Internet Addiction (n = 120)

25. stages of psychotherapeutic Research: Phase of Legitimation: Question of efficacy - Is psychotherapy effective? Phase of Competition:Question of comparable effects ? Phase of Prescription:Question of differential indication? Phase of Process Research:Question of the mode of functioning (How/in what way works the psychotherapy?) quality of intervention studies: (Pharma, Counselling, combined, CBT) … studies are lacking in inconsistencies in the definition, diagnosis, and measurement of disordered use; lack of randomization and blinding; lack of controls; and insufficient information on recruitment dates, sample characteristics, and effect sizes…. Grawe et al., 1994

26. Clinical study (RCT) to evaluate the outpatient psychotherapy Effects of a manualized Short-term treatment of Internet and Computer game Addiction (STICA) - Goals of the study:  Analysis of Efficacy of the CBT Short-term treatment for Internet and Computer Game Addiction  Investigation of the stability of treatment outcome  Influence of Short-term treatment on psychiatric symptoms • multicenter design: 4 study centers (Mainz, Mannheim, Tübingen & Vienna) • estimated duration: 36 months • estimated number of subjects: 192 patients

27. manualized outpatient group psychotherapy 1. Phase: Psychoeducation & Motivation 2. Phase: Intervention 3. Phase: Termination and Stabilization • Psychoeducation on mechanisms of addiction • Elaboration of an individual model for the development and maintanance of addiction • Motivation for abstinence • Definition of therapy goals • Functional analysis of the addicitve behavior (diary keeping) • skills training (e.g. coping with negative emotions, stress and problems, social skills, self-monitoring for reducing procrastination tendencies etc.) • promotion of social communication • exposition training • elaboration of tools preventing a relapse • review of transfer of treatment tools to daily life • functional computer/ internet use • Emergency plan Session 1 - 3 Session 12 - 15 Session 4 - 11

28. Types of Internet Addiction (subforms of internet-Related Disorders, IRD) • Age: • STICA: 25.97 (±8.67) WLC: 26.06 (±6.97) • Screen times: (weekday) • STICA: 6.54 (±3.07) • WLC: 5.74 (±3.10) • Screen times: (weekend) • STICA: 8.39 (±3.90) • WLC: 7.61 (±3.65) • Online gaming: • STICA 54.9%; WLC 59.7% • Online-Sexpages: • STICA: 14.1%; WLC: 18.1% • Consoleand Offline gaming: • STICA: 7.0 %; WLC: 5.6% • othertypes: socialnetworks, online shopping, research/ compulsive Surfing (nearly same percentageeach)

29. Primary efficacy endpoint: Improvement of IA / CA: Change of level of the AICA-S Logistic Regression modelled for AICA-S: non-pathological, on categorial level, ITT Population, N=143 a significant influence of the treatment on AICA-S over time was found (p<0.0001). • primary endpoint is defined as change of the symptoms-score (a post-treatment value < 13 means remission of IA). The adjusted Odds Ratio for STICA vs. WLC is 10.43 • subjects in the STICA-group have a 10.43 times increased chance to change their symptoms-score to „non-pathologic“ after the treatment, than patients in the control-group • comorbidity, center and age had no significant influence on the results

30. Media skills training for adolescents (12-16) in the Department of Psychosomatic Medicine and Psychotherapy

31. 16 years of age, male, daily gaming: Ø 7 hours Why are you here? presumedgamingproblem problemswithmyparents high levelofaggression + angryoutburstswhenhe‘s not allowedtogame, not interested in otheractivitiesandnophysicalactivity Mother: 31

32. Media Skills Training targetgroup • agerange: 12 – 16 years • suspectedofinternetaddictionorgamingdisorder • Decreasedperformance in school • generalmotivationforchange content • weeklygroup-basedsessionswithupto 8 adolescents • familyinvolvement exclusioncriteria • global assessmentoffunctioning (GAF) < 40 • untreated ADHD • high levelofaggressionagainstparentsorpeers • langanhaltende Schulverweigerung • deepdepressionorsubstance-relatedaddiction

33. Media Skills Training Session 1 • participantstalkaboutthemselves e.g. housingsituation, gaming, hobbys • similarities? • reasonforparticipation: voluntary, parents? • self-motivation • expactations • formulateobjectives • agreement

34. Actualstate „time-cake“ meal sleep: 7 hours school: 6 hours homework / Meal: 1-2 hours PC: 8-10 hours sleep PC school homework/ meal

36. Pre-Post comparison Reductionof time ofuse participants, whocompletedthetreatment : Pre at schooldays: 7,6 hours at freedays: 10,6 hours Post at schooldays: 4,5 hours at freedays: 4,3 hours - 3,1 hours - 6,3 hours

37. Discussion furtherdevelopment • focusmore on devolopmentofself-motivation andcommitment at thebeginning • strongerinclusionoffamilyaspectsintothechangeprocesstoachievelong-term effects, e.g. groupsfor relatives • higherfrequencyof additional singleandfamilysessions • furtherimprovementofthedysfunctionalinteractionpatternsandcommunicationbetweenparentsandchildren

38. Thank you for your attention!

39. Typical lifetime events of a patient in a self drawn time course Intensity of internet/ computer use satisfaction with social life life-satisfaction Elementary High school studies/training/work