The Hybrid approach (MINT) in working with Net-addicts

Forward

“In the past ten years, there are many articles which describe the problem of internet addiction but few of them discussed about the intervention strategies.” ¹

I think it is a very good remark for those who attempt to develop a unified approach in working with the problem of internet addiction.

In this reflection, some of my general observations of internet addiction which I find they are striking will be discussed firstly. The discussion will be unfolded from three different aspects: the addicts, the parents and the therapists. As our working group adopts Motivational Interviewing and narrative therapy (on the basis of systemic thinking) as the major working approaches; I thus attempt to explore the possibility to make use of them complementarily. On top of these two approaches, I would like to propose a hybrid approach, namely MINT to work with net-addict. The formulation of the approach and the brief notes of its intervention will be the focus of discussion.

In addition, to figure out how to develop a framework for glooming practice wisdom is another attempt of this reflection. Nevertheless, to evaluate the appropriateness of applying this hybrid approach is not the focus of this reflection although I value very much of its importance.

 

General Observation

1. Strongly agreed with the observation of the previous quoted article that most young net-addicts usually come with a rather low awareness of the hazards of internet addiction. They also disagree that they addict to internet and lack of motivation of change. By using the language of the Wheel of Change, they are at the stage of pre-contemplation. To assist the client migrate from the stage of pre-contemplation, let say, to the stage of contemplation is definitely a great challenge and create great difficulties for intervention.
2. The age of addicts who firstly and heavily engaged in internet activities is various. Nevertheless, most of them start their heavy internet engagement in primary four to five or in form one to two/three and the risky period is in long vacation.
3. After addicted for 2-3 years, their schoolings are seriously fall behind and the family relationships are also adversely affected. They usually lead a very unidirectional mode of living. Finally, some of them are either being school drop-outs or being Hikikomori-s. These survivors of internet addiction who has already expelled (psychological or physical) from those nurturing systems deserve our great attention and invite different kind of intervention strategies. It is because the presentation of their problem may not belong to any stage of the Wheel of Change. If there any, I would say they are in the stage of disorientation.
4. Gender differences are also observed. Boys like to engage in more task and achievement orientated activities such as computer gaming; while girls are fond of engaging in relational orientated activities.
5. Interestingly, I am also come across some natural-recovered cases. Some of them recovered very well if the parent-child relationship is well preserved or period of addiction was not so long.
6. Moreover, changes of circumstances such as having a dating, repeating a class, changing of peer group, having a short-trip, expressing a sense of boring after a long period of engagement in computer gaming or even the breaking-down of a computer may be a very good chance for intervention.
7. On the other hand, it is not rare for medical professional to identify the nature of co-morbidity in serious internet addictive behaviors. Therefore, only focus on working with internet addictive behavior may also cover-up the problem of co-morbidity.
8. The correlation between family circumstances (i.e. parenting style and IT knowledge of parents) and the problem of youth internet addiction is still in need of further study. However, as observed, the participation of parents in the helping process is a very significant factor for effective intervention. They function as monitors, encouragers, collaborators, witnesses and plan executors.
9. Parents find themselves be more acceptant and tolerant when they understand the reason, the process/cycle of addiction and its corrosive power. This is especially important for them to develop a more realistic goal during the intervention process. The degree of their cooperation will also increase.
10. To assist parents to de-link the strict causal effect between internet addiction and other behavioral or emotional problems such as unsatisfactory academic achievement is also helpful. For example, a few numbers of parents hold this simple idea: internet addiction is the only factor adversely affects their children’s academic achievement. They believe that if their children do not play computer, he will then go to study. Once get out from these kinds of simple ideas, parents can evaluate the children’s situation with a more holistic manner and will be more ready to explore other alternatives.
11. Another observation is about therapist who usually adopts the conventional understanding towards internet addiction. He/she will perceive internet addiction is a means to fulfill psychological needs and to cope with various life stresses. Of course, they are especially validate at the initial stage and also supported by researches. Nevertheless, internet addiction will then only be perceived as a subordinate to the about mentioned difficulties. The implication will be: when the dominant problems are solved or the needs are fulfilled, the problem of internet addiction will then be alleviated subsequently. Nevertheless, these convention understandings may also blind us from fairly evaluating the proactive and productive nature of internet activities. Additionally, addictive behavior has its self-sustainable features. In other words, although the initial conditions of the addictive behavior are changed, net-addict will still keep his/her behavior. Therefore, it is unfavorable to solely classify the internet addictive behavior into a relational and/or developmental problem without paying attention to its self-sustainable features such as the psychological and physiological dependency as well as the ‘environmental pacification effect’. Therefore, although the initial supportive conditions of internet addiction have changed (i.e. the positive change of parenting) but the addictive behavior may continue. Parents will find this experience is very defeating.
12. Exposure to various up-to-dated internet activities is definitely an advantage.

… (more can be added)

 

Brief comparison between Motivational Interviewing and narrative therapy

As mentioned before, our working group adopts Motivational Interviewing (MI) and narrative therapy (NT) as the major working approaches. Therefore, here I will focus on briefly discussing about their theoretical underpinnings and the practices with my limited or even twisted understandings and studying how they can work together complementarily.

 

Comparison on theoretical level

Comparison on practical level

Elaborations

1. Addictive behavior goes through at least four identifiable stages. They are experimental, recreational, early dependency and full dependency stage. However, it should not be understood as ‘the earlier stage the more motivation one will have’. Actually, different stage has its expression of the change pathway.
2. Addictive behavior has its self-sustainable features. In other words, although the initial conditions of the addictive behavior are altered or even harms to oneself, addict will keep his/her behavior. Therefore, it will be unfavorable to solely classify the internet addictive behavior into relational and/or developmental problems without paying attention to its self-sustainable features.
3. Addictive behavior narrows the choices and possibilities of our clients. They could not but just surrender them totally and continually to a particular mode of behavior or living pattern, although sometimes they know that they should stop or make a change. However, these interruptions do provide client with a chance for breaking through if it can be properly used.
4. As observed from the above brief comparison, MI offers us an easy-to-read map for intervention, which keeps on reminding us where we are, and what and why we are doing so. While NT approach helps us to dig into the details slowly and to expose the richness of one’s life – those richness are the indispensable resources for personal growth and building of new identity and behaviors. From the perspective of NT, a problem saturated story keeps us away from any possibility.
5. In addition, the four general principles of MI practice (express empathy, develop ambivalence, roll with resistance, and support self-efficacy) which proposed by Miller and Rollnick also provide us with a clear framework to engage our clients into change talk. Therefore, the MI approach, other than offers us an easy-to-read map to work with addicts (though it is very brief and need to be enhanced) but also provide us with a favorable approach to foster a good and effective engagement.
6. To accurately identify the symptoms of different stages and the signs of moving from one stage to the other stage is very important to our intervention. However, a map will not plan for you. To identify the signs/symptoms/stages, to figure out where the client is and to work out a walkthrough together with the client are the duties of therapist. By this understanding, the questioning approach of NT can play a comparatively significant role in this part of intervention.
7. A story composes at least five essential elements; they are subject, object, time, space and action. The interweaving of these five diversifies our stories. Episodes of storytelling can be understood and organizing into different themes. Through exploring these themes by scaffolding and sometimes by de-construction, new possibilities may evoke.
8. Obviously, the two working approaches are originated from different philosophical and therapeutic traditions. Therefore, the marriage of MI and NT is in extremely pragmatic sense.

 

The formulation of MINT

The MINT approach basically composes of three major layers which represent three fundamental concerns:

All counseling approaches emphasize very much on the importance of a good working alliance, however as we know, good working alliance alone cannot lead to the increase of motivation . Furthermore, motivation is also not enough to lead to a sustainable change. Just like what MI reminds us, it is not rare for the client to have the ‘yes but…’ symptom – a state of ambivalence .

As reviewed, there is no notable contradiction between the MI and NT approaches regarding the cultivation of good working alliance and the promotion of client’s motivation of change. In other words, these two approaches can have their distinctive contributions on the first two layers. It also provides us with a common platform for developing the MINT approach. In addition, concerning the first two layers, we mainly use MI to formulate our map of change in this approach. There are at least six landmarks have already laid on the map.

However, the map alone cannot tell us how we can move from one stage to the other stage. Therefore, we use narrative therapy as a useful tool to identify and scaffold the transformative structures which are necessary for promoting change.

For the third layer, when we talking about change, it implies that something ‘moves’ from state A to state B and these two states must be different – no matter it is good or bad. Otherwise, we cannot say there is undergoing a change . Furthermore, at least three apparent components can be identified in a changing process. They are the state A(starting point), the state B(destination) and the process of migration.

In the MINT approach, the first two components and their attributes will be dealt with MI while the last one, the process of migration is left to NT.

In sum, MNIT is concerning about the study of the above mentioned micro -changing process and how to make it happened. For example, there have five micro-changing processes in the Wheel of Change. We understand that each micro-changing process involves distinctive dialogical patterns and tasks to be fulfilled by the client and the therapist.

 

Notes to intervention
Here we will not discuss the micro-practices but the general principles of MINT. The discussion will correspond to the three-layer structure of the proposed approach. As the first two are closely related and partly over-lapped, therefore, they will be discussed together.

Developing working alliance and promoting motivation
The quality of the working alliance and the motivation of a client can be reflected by his/her level of participation during interview. The MI approach can help therapist to identify those traps and attitudes which will paralyze the energy and upset the momentum of interview. A successful engagement is the stepping stone for moving forward and developing further success. The basic tone of our intervention is very deterministic to our whole process of intervention – this is especially important in the early stage of intervention. The practice of curiosity and not-knowing attitudes can give us a hand to promote the level of participation and to reduce the ‘noise’ of conversation in the process. The following meta-questions which may help:

1. What kind of stage the client is in?
2. What are the reasons and justifications which support my observation?
3. Do I communicate adequate interest/concern towards the client?
4. Do I open up adequate narrative space for the client?
5. Do I engage the client into a change talk or a resistance talk?
6. If necessary, how can I energize the process of interview?
7. What kind of maintaining factors that prevents the client from moving into the next stage?
8. It there any critical moment/incident which I can make use of?
9. What are the implications of the client’s mode of internet engagement?

Making change
Michael White in his working approach stresses very much on the ‘de-centered but inferential’ practice. In other words, we are not just waiting for and /or maintaining the client’s motivation of change, but also we should ‘trigger’ the happening of it. Therefore, therapist is expected to use language as a device and other tangible or non-tangible resources to make thing happen! Specifically, therapist can scaffold transformative structures for inducing changes. Base on those structures, one can move forward to a new set of behaviors or identities. Narrative practice, from my point of view, can contribute a lot in this aspect.

Structure, here refers to any construct which is specifically ordered, comparatively stable and relatively self-sufficient. We can make sense to its elements contained through such a structure. For example, take ‘13’ as a symbol. It will have different representation/meaning in different structure, let say, in numeric structure, it represents thirteen; while in alphabetical structure and the symbol can be taken as the capital letter B.

Moreover, a structure and its elements are mutually conditioned. When there comes a new element, the process of assimilation, or accommodation or transformation will happen, which depends on their strength. For example, a strong/stable structure comes with a weak element, assimilation will occur; if a strong element comes with a relative weak structure, transformation will occur.

In counseling process, some of these so-called structures will be narrated by the client obviously or implicitly. Or some may come from life event such as repeating a class or the death of a significant other. Some structures are very rigid and some are not. If these structures which can be made use to facilitate the changing process, they are specified as transformative structures. Some of them are presented and some are in need of scaffolding. Taking the following case as an example, when client revealed, ‘I realized that ‘my freedom is corrupted’ when I keep on playing online games.’ Obviously, this is a presented transformative structure. What therapist can do is to thicken this structure by specific questioning approaches. One of the therapist’s responds can be: ‘Hey, it sounds very interesting! I heard that you have a totally different experience of playing online game. You said it corrupted your freedom, would you please tell me more about this experience?’ Or we can start to address the structure by having a brief summary and use the skills of selective focusing .

On the other hand, some of the transformative structures are implicitly presented and their elements are scattered, which are necessary for thematizing and scaffolding by the joint effort of the client and the therapist.

As mentioned before, we can take reference to the five kinds of questioning which proposed by Narrative Therapy during the process of scaffolding. The following meta-questions may help:

1. How does the client narrate his experience?
2. Is there any presented transformative structure that we can make use of? Or is there any implicitly but comprehensible transformative structure deserving our attention and waiting for our developing.
3. How can I scaffold the transformative structure by linguistic and materialistic (non-linguistic) resources?
4. Is the client ready to migrate to the next stage?
5. What are the justifications for this observation?

Needless to say, the above mentioned micro-practice occupied a very central and significant position that in fact is necessary for further polishing. It can also be one of the major focuses of glooming our practice wisdom.

 

Case assessment
It sounds very strange to discuss about case assessment at the finally part of intervention. However, preventing the process of case assessment and fact finding from dominating the intervention is very importance in working with those not-ready net-addicts. On one side, we emphasize the client’s right to have his/her narration presented according to his/her personal preference. On the other side, it is because the process of fact finding may easily end up in a very discouraging process. It may also upset the momentum of interview. What the most important point is the process of interview is to create experience but not just for collecting of information.

Additionally, it is necessary to cultivate an environment for phenomenological listening because this can avoid paralyzing the energy level and falling into the communication traps. This environment is strongly emphasized in our practice because the tone, the use of wordings and the order of narration are very important for thematization and scaffolding of transformative structure.

Fact finding and case assessment, like working with other clientele, are extremely important for an effective intervention. For example, they can help to eliminate the possibility of having co-morbidity and to identify those less rigid structures that can be re-appropriated. This process also heavily relies on our sensitive to the client’s use of language and its expression. The following figure suggests some common structures we can attend to. Besides, we can also make reference to the Case Assessment and Intervention Form.

Suggestions on glooming practice wisdom
Regarding to the framework of the hybrid approach, I will suggest focusing on the following three major aspects to accumulate practice wisdom through sharing of clinical practices:

1. Enhancing the map – to sharpen our identify skills of different signals/symptoms of different stages of the addictive behavior and the Wheel of Change. Let say, when we say someone is at the stage of early dependency and locate at the stage of determination, what are our justifications? What are the unique expressions of these signs/symptoms which we can identify from net-addicts? How the addicts present the signs/symptoms in behavioral and ideological sense? (to study the signs/symptoms of stage and its unique expression)
2. Identifying and developing transformative structure – to increase our sensitive to the explicit or implicit transformative structure, and to develop effective strategies to scaffold those structures. (to build and to study the transformative structures which indicate a person who is ready to migrate from one stage to the other stage, i.e. the arrow between two stages)
3. Identifying the critical moments/incidents – to increase our awareness to identify related critical moments/incidents and to make a good use of them to promote motivation and change.

Our ultimate goal is to develop and accumulate those comparatively effective dialogical patterns and specific ways of questioning which are feasible for developing transformative structures, and those critical moments/incidents which can be used to promote change.

Epilogue
Definitely, this piece of reflection is only a very preliminary attempt to sum up my working experience as well as the inspirations which come from the group discussion of the Task group on Working with Internet Addiction. In fact, I know there are many concepts await further clarification and this so-called hybrid approach does involve many micro-practices that need to be put into practice and examine rigorously, otherwise, it is only my fascinated thinking.

 

Footnote:

1. Abstracted from 《香港協助網絡成癮青少年的工作成效評估》。The Hong Kong Journal of Social Work, Vol. 42, No.1/2, p.122。The original text is: 「過去十年，描寫網絡成癮問題的文章不少，但建議介入方法的則寥寥可數。」

 

Extended reading:

1. From a fact to a structure