Testing the efficacy of group cognitive-behavioral therapy for pathological internet use among undergraduates in Nigeria

Abstract Introduction The aim of this study was to examine the effect of group cognitive-behavioral therapy (GCBT) on pathological internet use (PIU). Method The study applied a group randomized controlled trial design to assign participants to intervention and control groups. A total of 40 college students aged 18 to 30 who were pathological internet users (PIUs) participated in this study and were randomly assigned to treatment and control groups. Participants completed a self-report scale entitled the Problematic Internet Use Scale (PIUS) at three time points. The intervention lasted 8 weeks. The data collected were statistically analyzed using repeated-measures analysis of variance (ANOVA). Results The results showed that GCBT has significant efficacy, decreasing the symptoms of PIU among the GCBT participants compared to those in the control group and that the improvements were maintained at follow-up. We also found a significant interaction effect by time for PIU. Conclusion From the study findings, we can conclude that GCBT has significant benefit for mitigating the severity of PIU in college students. Therefore, mental health professionals are encouraged to explore the benefits of GCBT in treating symptoms associated with PIU in school settings and beyond.


Introduction
Pathological internet use (PIU) describes spending excessive resources (e.g., time, money, energy) on various activities on the internet to an extent that it might have harmful effects on the person's physical and psychological condition, social, academic, professional, and interpersonal relationships, and other areas of life. [1][2][3] Concepts such as excessive internet use, problematic internet use, internet addiction, internet abuse, unregulated internet use, and compulsive internet use have been used interchangeably with PIU. 4,5 Like other addictions, PIU may be seen as an impulse-control disorder and can be linked to a variety of problems. PIU has characteristics like pervasiveness, depression, withdrawal, tolerance, and negative effects on daily functioning. 6,7 Some health problems like headache and sleep pattern disruption might occur due to prolonged use of the internet. 8,9 The sleep patterns of people with internet addiction are interrupted due to late night internet surfing leading to excessive fatigue, and impairment of the immune system, which leaves people with internet addiction prone to disease. 3,10 Excessive use of the internet has led many students into risk of loss of significant relationships, sleeplessness, depression, and academic and social problems. [11][12][13] Students' overuse of the internet may interfere with their adaptive functioning, leading to depression as well as psychological disorders. [14][15][16][17] Students have been considered vulnerable to relational problems because of over-accessibility of the internet. 18,19 PIU among younger people has also been found to have a significant relationship with loneliness, 20,21 negative self-esteem, 17 symptoms of antisocial tendencies and externalizing control, 22 shyness, 23 and social disinhibition. 24 As a result, it is important to help professionals to recognize the signs and symptoms of PIU and learn about some of the emerging treatment strategies for assisting college students with PIU disorder. 25 Concern has been raised over excessive use of internet activities among college students in Nigeria. [26][27][28] High levels of prolonged internet use and associated psychological and physical health problems including sleep disturbances and backache have been identified among students in colleges in Nigeria. 29,30 Poor academic performance has also been linked to PIU among (Nigerian) students. 26,31 Vices driven by PIU, including internet fraud and related crimes and vices, have attracted wide criticism in Nigeria. However, we found no studies attempting to practically address students with PIU problems in Nigeria. Some researchers have suggested application of therapeutic interventions to decrease the severity of PIU. 18,19,32,33 The current study aims to employ cognitive-behavioral therapy to address PIU problems in a Nigerian college sample.

Cognitive-behavioral therapy (CBT)
CBT 34 is anchored in the assumption that reaction to automatic thoughts may lead to abnormality.
Beck proposed that how people think (cognition), feel (emotion), and act (behavior) all interact to influence them. 34 Automatic thoughts can cause negative consequences which may affect our cognitive, behavioral, and emotional responses. 34 Beck et al. 35  The CBT approach uses cognitive restructuring to change core thoughts and improve problem-solving skills towards acquiring desired adaptive behaviors.
The CBT approach has been widely found to be beneficial in alleviating impulse control disorder. [36][37][38][39][40] Because PIU could be accompanied and characterized by dysfunctional thoughts, 41  Our study will provide additional evidence regarding the effectiveness of CBT in a poorly explored setting.
Specifically, this study examines the effect of group cognitive-behavioral therapy on PIU among students in Nigeria. We hypothesized that group cognitivebehavioral therapy will be significantly effective in reducing PIU among students. We also hypothesized that the significant effect of group cognitive-behavioral therapy in reducing PIU among students will be sustained at follow-up evaluation.

Ethical approval
An

Design of the study
This is a group randomized controlled trial design which involved pre-testing and post-testing of participants. Participants were randomly assigned to an experimental group (i.e., GCBT group) or a control condition (i.e., waiting-list group). 50

Participants
The researchers recruited a total of 40 participants The revisions to these diagnostic health tools have clinically classified PIU as a mental and behavioral disorder. 52 Exclusion criteria were ongoing psychological treatment, receiving medication, and not meeting the criteria for classification of the conditions in DSM-V and ICD-11. Specifically, the college students who were excluded due to psychological treatment and receiving medication were sick patients (e.g., with anxiety disorder). After the recruitment exercise, 40 participants were randomly assigned to two groups: the treatment group (n = 20) or a waitlist control group (n = 20) by the researchers. The randomization process adopted a simple random allocation sequence, using Random Allocation Software developed by Saghaei 53 (see Figure 1) that was implemented by the researchers.

Measure
The generalized Problematic Internet Use Scale 2 In session three, the participants were allowed to discuss the problems they encountered in their studies that could be linked with PIU. Some of these problems  were also committed to monitor the students' activities.
Given these precautions, no dropouts were recorded during the study. The researchers collated the data from the participants directly after each assessment.
This is a blind study in which the researchers did not disclose the identities of the participants to the data analysts to avoid revealing which participants were in the intervention group and which were in the waitlisted group. This was to ensure concealment of information during the study. To ensure there were no missing responses, we engaged three data analysts, each to analyze one set of assessment data e.g., Time 1.

Therapists
Two therapists were recruited and engaged for this study to deliver the intervention. They were two counseling psychologists trained in guidance and counseling who had both obtained Masters degrees.
They were licensed to practice by the Counselling Association of Nigeria. They were within the age range of 32 to 45 years with about 5 years of experience.
The researchers briefed them about the goal of the treatment and how to deliver the manual given to them.

Treatment integrity
Based on the importance of effective and adequate implementation of the GCBT-program manual, we assigned two researchers who are also part of the research team to monitor the implementation processes of the intervention. Specifically, the integrity checkers or raters were designated to ensure that the therapists followed the guidelines and steps enshrined in the treatment manual. As part of their roles, they recorded the participants' and therapists' attendance. That is, the number of times each participant attended sessions.
They took note of the number of times each participant asked and answered questions during the treatment sessions. They also monitored the participants' and therapists' behavioral and emotional responses.

Treatment manual
The are also included in the treatment manual (see Table 1 for summary). We developed the current manual taking cognizance of cultural differences and the fact that already existing manuals did not focus on PIU.

Data analysis
The data received were subjected to analysis of variance (ANOVA). Partial eta squared was used to measure the effect size and to determine whether the two groups have similar standard deviations. 56 The effect size was determined using limit number of   As shown in Table 3, the values of showed that at baseline level there was no difference,

Discussion
This study aimed at exploring the effect of GCBT on PIU among undergraduate students. Excessive use of the internet could cause academic, social, and interpersonal problems. 24 After the intervention, the repeated-measures ANOVA statistic showed that GCBT helped to decrease PIU among college students. We also found that the effectiveness of GCBT was sustained at 1 month follow-up. The findings of this study also support Du et al. 58 who indicated that group cognitive behavioral therapy decreased schooling adolescents' internet addiction. Another study conducted in Germany revealed positive therapeutic effects of a cognitive behavioral group program in improving lifestyle of youngsters who were affected by PIU. 59 Like the finding of the present study, an earlier study found a long-term effect of cognitive behavioral therapy on youth with PIU. 60 The finding is also consistent with the study of Wartberg,59 who found that group therapy enhances significant change in people with PIU. This is in consonance with Kim 25

Practice implications
Implications of this study are that GCBT could help in reducing PIU. Mental health professionals in practice could use GCBT in counseling students who use the internet excessively. Granted that the severity level of psychological symptoms associated with PIU in male and female college students could be minimized using GCBT, we encourage Nigerian public health professionals and other helping professionals to explore cognitive behavioral technique in reducing substance abuse.
Since the study outcome revealed the long-term effects of CBT, cognitive behavioral therapists, psychologists, school counselors, teachers in colleges, and other schools should adopt the principles of CBT in helping students with behavioral problems. [76][77][78][79] By practicing the assumptions of CBT, inappropriate behaviors such as pathological behaviors and the types in which students excessively indulge in could be reduced using CBT.

Limitations of the study
One of the main limitations of the study is the use of the PIUS. Since the PIUS is not a mechanism of change tool, its use may affect the generalizability of the findings.
Moreover, the scales are only quantitative measures.
Participants were not well characterized in terms of cognitive performance, psychological problems, etc. We did not take into account other factors that could affect the results obtained. Future research could explore triangulation methods involving the assessment of significant others in monitoring change in PIU problems.
It could be that certain individual/group dynamics were responsible for significant change in behavior rather than the GCBT. Our design was however not structured to identify the influence of different sessions. Future studies could isolate and monitor group and individual factors that may possibly influence treatment outcome.
We also acknowledged that one of the major limitations of this study is its small sample and use of only Federal College of Education students. This methodological weakness tends to affect the generalizability of the results. We strongly advise readers of this journal to exercise caution in interpreting the outcome of this study. To that end, we encourage future studies to use larger samples. Given the limitations of this study, future studies that report the findings of the study should exercise caution in generalizing the study outcome to other groups in the education sector like teachers and other populations outside Nigeria.

Conclusion
Owing to the prevalence of PIU, this study has investigated the effectiveness of GCBT on undergraduate college students with PIU. We found that GCBT significantly reduced PIU among the undergraduate college students. The result indicated that the effectiveness of GCBT on the college students' PIU was sustained at follow-up assessment.