Irresistible

by Adam Alter

  The teens themselves recognize this. They’re sophisticated in ways that escape the adults who grew up in a relatively primitive world. A group of teenage boys at the center discusses their addiction in a show of masculine one-upmanship. One says he played a video game for two months straight without quitting—the full extent of his summer vacation. Another chimes in and says he played for three hundred days, stopping briefly to eat, sleep, and use the bathroom. A third calls Professor Ran’s definition of addiction “bullshit.” Six hours a day seems normal to him. “If you check their definition of Internet addiction, 80 percent of Chinese must have it.” A fourth says, “Most of us don’t think we have Internet addictions. It’s not a real disease. It’s a social phenomenon.” The boys try to minimize the issue, but it’s clear that Internet addiction is a massive and growing problem in China.

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  The Western approach to behavioral addiction is just as scattered as Professor Ran’s approach. The Diagnostic and Statistical Manual now recognizes that gambling is a genuine behavioral addiction, and excessive Internet use was almost included in the DSM’s fifth edition, published in 2013. There are now more than two hundred academic papers on the topic of “Internet addiction,” so the American Psychiatric Association chose to mention it briefly in the manual’s appendix. Meanwhile, the DSM omitted other behavioral addictions, like exercise, smartphone, and work addiction, because they hadn’t yet attracted enough academic interest. That doesn’t make the experience of these addictions any less real, though, as I discovered when I spoke to behavioral addiction treatment experts. Even if the APA doesn’t consider them diseases or disorders, they still affect many thousands of lives. And perhaps they shouldn’t be considered clinical disorders at all—perhaps, like the millions of Chinese teens who treat loneliness by turning to the Internet, behavioral addicts are just responding to the constraints of the world they happen to inhabit.

  In contrast to Professor Ran’s medical model, with its pills and psychiatric treatment sessions, reSTART primarily treats behavioral addiction as a structural issue: fix the structure of the affected person’s life and you’ll fix the problem. Therapy sessions form a small part of reSTART’s treatment plan—far smaller than, say, life training and coping skills. But that isn’t true of every U.S. facility. There is one hospital that treats behavioral addiction much as Western medicine treats substance addiction. The Bradford Regional Medical Center in Pennsylvania launched a ten-day inpatient treatment program for Internet addicts in 2013. Kimberly Young, the psychologist who founded the program, became interested in Internet addiction in the mid-1990s. “In 1994 or 1995, a friend of mine told me that her husband was spending between forty and sixty hours a week in AOL chat rooms,” Young said. “Internet access was expensive then, at $2.95 per hour, so his habit became a financial burden. I wondered whether people could develop an addiction to the Internet.” Young created the Internet Addiction Diagnostic Questionnaire, or IADQ, which she posted online. Like gambling and alcohol addiction questionnaires, the IADQ asked respondents to indicate whether eight statements applied to them. “Anyone who said at least five of the statements applied to them was ‘addicted,’” Young told me.

  The next day dozens of people emailed her to say they were concerned. Many of them were scoring above five on the scale. Over the next four years, Young refined and validated the questionnaire, added twelve new items, and renamed it the Internet Addiction Test. (I included a sample of questions from the test in the first chapter of this book.)

  Young began to treat a growing list of Internet addicts, fueled by two specific events, first in 2007 and then in 2010: the introduction of Apple’s iPhone and then its iPad. “My focus on Internet addiction exploded when the Internet went mobile,” Young told me. The addiction context was no longer limited to the home—now it was everywhere. By 2010, Young recognized the need for a dedicated treatment center. A long-out-of-date study in 2006 suggested that one in eight Americans was addicted to the Internet, but Young was convinced the number was much higher—and rising. She managed to secure sixteen beds at Bradford, which were set aside for an acute Internet addiction treatment center. She had spoken to Cash at reSTART, but Young preferred a different, more intensive approach. Instead of forty-five days, patients would stay at her facility for just ten days. “Most people don’t have time to spend longer than ten days with us,” she said. Many of them had seen other doctors who couldn’t help, so by the time they arrived at the hospital, they were desperate. They would undergo a rapid three-day detox, and then seven days of targeted cognitive-behavioral therapy. Young’s approach, known as Cognitive Behavioral Therapy for Internet Addiction, or CBT-IA, borrowed techniques that had been successful in treating other impulse disorders. Many of her patients don’t believe they have a problem, so she has to teach them to recognize that they are, in fact, addicts. Then she teaches them to reframe some of the harmful ideas that lead them to overuse the Internet—for example, the notion that they’re incapable of forming friendships offline. CBT-IA also encourages patients to re-engage with the offline world, which many of them have abandoned in favor of an online world that seems more forgiving.

  In 2013, Young published a paper that described the effects of CBT-IA on 128 Internet addicts. She measured their progress immediately after twelve treatment sessions, and again one month, three months, and six months after treatment ended. The results were encouraging: immediately after treatment, Young’s patients were less preoccupied with the Internet, more capable of managing their time, and less likely to be experiencing harmful consequences from overuse. Six months later some of the treatment benefits had weakened, but the patterns were similar: CBT-IA seemed to be working, at least on this limited sample.

  Programs like reSTART, Kimberly Young’s CBT-IA, and Professor Ran’s military academy are desperate attempts to deal with the most severe cases of behavioral addiction—and they’re restricted to Internet and gaming addiction. They aren’t perfect, but early evidence suggests that they yield small to moderate benefits. But what are we supposed to do with the remaining millions who aren’t ready or able to be inpatients—the millions who exercise too often, work longer hours than they should, and can’t help spending too much money online?

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  The answer is not to medicalize these moderate forms of addiction, but to alter the structure of how we live, both at a societal level and more narrowly, as we construct our day-to-day lives. It’s far easier to prevent people from developing addictions in the first place than it is to correct existing bad habits, so these changes should begin not with adults, but with young kids. Parents have always taught their children how to eat, when to sleep, and how to interact with other people, but parenting today is incomplete without lessons on how to interact with technology, and for how long each day.

  Like Alcoholics Anonymous, many clinical programs promote abstinence: either you abstain from the addictive behavior, or you’ll never shake the addiction. Since abstinence isn’t a practical option for many modern behaviors, one alternative intervention takes a different approach. Where Alcoholics Anonymous suggests that addicts are helpless to overcome their addictions, motivational interviewing rests on the idea that people are more likely to stick to their goals if they’re both intrinsically motivated and feel empowered to succeed. Counselors begin by asking open-ended questions that encourage their clients to consider whether they want to change their addictive behaviors. What makes the approach radical is that clients are allowed to decide they don’t want to change their behavior at all.

  Carrie Wilkens, cofounder and clinical director of the Center for Motivation and Change in New York City, explained the process. “The key to motivational interviewing is getting the costs and also the benefits of the addictive behavior on the table. We all know how terrible addiction is, but it also has benefits, and this tends to be the most meaningful part of the puzzle. Unpacking the behavior’s benefits is great because then you c
an understand the underlying needs that the behavior addresses.”

  If, for example, a sixteen-year-old girl checks her Instagram account dozens of times a day, she might say that the benefit is that she feels connected to her friends. She posts pictures three or four times a day, and feels compelled to check whether her posts are attracting likes. The key to treating her addiction, then, is to make sure she feels connected through other means, and that she feels validated in the absence of those likes. A typical session with the girl might begin with something called a readiness ruler:

  On a 0–10 scale, if 0 is not in the least bit ready to change your behavior, and 10 is as fired up as you can be, where are you?

  The first question in the primary intervention probes the girl’s response to this question. Why is the number so high or low? This gives her a chance to express her willingness to change. If she gives a low response, she might say she doesn’t see any need to change her behavior; with a high response she might admit that her Instagram use is making her unhappy. From there, the clinician asks a series of open-ended questions:

  What are the benefits of your Instagram use?

  How would you like things to be different?

  How does your Instagram use affect your well-being?

  In what ways do you feel you could be doing better?

  Counselors who practice motivational interviewing complete rigorous training seminars, but the general approach has plenty of benefits for parents and even adults who are trying to change their own behavior. It’s non-judgmental by nature, so addicts are less likely to be defensive. One script, for example, suggests the following opening:

  I’m not here to preach to you or tell you what you “should” do; how would I know, it’s your life and not mine! I believe people know what’s best for them.

  I don’t have an agenda, just a goal: to see if there is anything about the way you take care of your health that you would like to change, and if so, to see if I can help you get there.

  How does that sound to you?

  Counselors traditionally used the approach to treat substance abuse, but Wilkens says it works just as well for behaviors. At least one study confirmed her belief. It works because it motivates people to change, and gives them a sense of ownership over the process. They aren’t being cajoled or pressured to change by someone else; they’re choosing to change voluntarily. The approach also recognizes that different people are driven to overcome their addictions by different motives. For some people, addictions are a barrier to productivity; for others, a barrier to health; and for many, a barrier to fulfilling social relationships. Motivational interviewing uncovers that motive, and prompts the addicted person to change.

  The technique’s effectiveness is explained by one of the dominant theories in motivation research: Self-Determination Theory (SDT). SDT explains that people are naturally proactive, especially when a behavior activates one of three central human needs: the need to feel in command of one’s life (autonomy); the need to form solid social bonds with family and friends (relatedness); and the need to feel effective when dealing with the external environment—learning new skills and overcoming challenges (competence). Though addictive behaviors are designed to soothe psychological discomfort, they also tend to frustrate one or more of these needs. A motivational interview makes that frustration clear: if you’re asked how your Instagram use affects your well-being, you’re going to see that it’s compromising your productivity, your relationships, or both. Far from rendering a person powerless in the face of her addiction, she’s left to feel both motivated and capable of changing for the better.

  SDT emerged during the extravagant mid-1980s. Wall Street excess had reached a peak, and businesses believed that workers responded best to bigger paychecks and lavish perks. SDT suggested that these forms of compensation—known as extrinsic rewards—would fail to sustain motivation in the long run. What workers needed were intrinsic rewards: a job that made them feel effective and competent at a company they respected. Sometimes, extrinsic rewards were actually counterproductive, because they robbed workers of genuine intrinsic motivation. In one experiment, students enjoyed completing a series of puzzles—until researchers started paying them. As soon as they were paid, the students decided the puzzles weren’t much fun after all. When given the chance to continue working on the puzzles, they preferred other activities instead. SDT shows how important it is to design the right sort of environment, regardless of whether you want to promote or discourage a behavior. The key is to understand how different features of the environment—financial incentives and physical barriers, for example—shape motivation. A well-designed environment encourages good habits and healthy behavior; the wrong environment brings excess and—at the extremes—behavioral addiction.

  11.

  Habits and Architecture

  In the United States, politics and religion go hand-in-hand. Conservative states tend to be religious, and liberal states tend to be secular. That first category includes Mississippi, Alabama, Louisiana, South Carolina, and Arkansas. All five are Southern states that fall within the Bible Belt—the epicenter of socially conservative evangelical Protestantism. In contrast, Massachusetts, Vermont, Connecticut, Oregon, and New Hampshire are relatively liberal and secular. These two sets of states differ along countless dimensions, and among the most prominent is their attitude to sex. Conservative, religious states tend to endorse traditional sexual values while they discourage open and hedonistic attitudes to sexuality, which are far more accepted in liberal, secular states.

  One consequence of condemning open sexuality in public is that sexual expression goes underground. For example, teens are more likely to have unprotected sex in conservative states—even when you remove differences in income, education, and access to abortion services from the equation. Religious repression is no match for sex drive—and if anything it seems to exaggerate the urge. This is no surprise to psychologists, who have known for decades that repression doesn’t work. It’s almost impossible to overcome an addiction by sheer force of will. In 1939, Sigmund Freud first argued that people who rail against an idea are subconsciously drawn to that idea, and two of his disciples, named Seymour Feshbach and Robert Singer, proved him right.

  Feshbach and Singer were professors at the University of Pennsylvania in the late 1950s. Experimental ethics laws were lax then, so they devised an unpleasant experiment using electric shocks. One at a time, male psychology students watched a short video of a man completing mental and physical puzzles. A research assistant strapped a small electrode to each student’s ankles, which would administer a series of eight shocks as they watched the video. The assistant explained that the shocks would build in intensity, and that it was normal for the students to feel afraid. Half of them were told to express their fears—“to be aware of and admit your feelings.” The other half were told to suppress their fears—“to keep your mind off your emotional reactions and not think about them . . . to forget about your feelings . . .” When the video ended, they were asked whether the man they had seen on the video was afraid. As Freud had predicted twenty years earlier, the students who were asked to suppress their own fears believed the man was himself afraid. They were projecting the very emotions they had been asked to suppress onto the world around them. Those who were instead encouraged to express their fears were far less likely to believe the man in the video was afraid. By expressing their own fears, they were freed from the preoccupation with fear that plagued the suppressors.

  You might imagine that people in the libertine northeast and northwest states spend more time consuming porn on the Internet, but as Freud predicted long ago, the reverse is true. People from conservative states with traditional views of sexuality are more likely to subscribe to online pornography services. And according to two Canadian psychologists, it’s the people from conservative, religious states who search for porn-related terms more often. When Cara MacInnis and Gordon Hodson
collected data from Google Trends to examine the search behavior of people from each U.S. state, they found strong correlations between religious belief and porn-related Internet searches, and between conservatism and porn-related searches. In MacInnis and Hodson’s own words, “although characterized by an outward and vocal opposition to sexual freedom, regions characterized by stronger political right orientations were relatively associated with a greater underlying attraction to sexual content.”

  This gap between public and private behavior contradicts the myth that we fail to break addictive habits because we lack willpower. In truth, it’s the people who are forced to exercise willpower who fall first. Those who avoid temptation in the first place tend to do much better. That’s why heroin-addicted Vietnam vets fared so well when they returned to the U.S. and escaped the drug-taking context altogether, and why it’s so important to construct your environment so temptations are far away. According to Wendy Wood, a psychologist at the University of Southern California who studies habits, “Willpower is . . . about looking at those yummy chocolate chip cookies and refusing them. A good habit ensures you’re rarely around those chocolate chip cookies in the first place.” A combination of abstinence and willpower simply doesn’t work. In one study, Xianchi Dai and Ayelet Fishbach at the University of Chicago asked students in Hong Kong to abstain from using Facebook for three days. With each passing day they missed Facebook more acutely, and so inferred that they liked it more, and said they wanted to use it more often. (Students who used other social media sites as substitutes were immune to this effect—but that was only because they found another way to satisfy the same social networking need.)