Internet addiction: college student case study using best practices in cognitive behavior therapy.
As access to Internet technologies has increased, so too have behavioral disorders related to Internet use. Despite limited scientific research and competing or poorly defined constructs (Armstrong, Phillips, & Saling, 2000), mental health counselors nevertheless must assess and treat cases of Internet Behavior Dependence (IBD). We offer a framework for working with individuals who present with symptoms associated with Internet Behavior Dependence. In this article, we introduce a working definition for IBD, overview IBD prevalence rates and demographic profiles, then review IBD assessment criteria and treatment considerations. Following this, we introduce the use of Cognitive Therapy for treating IBD, then we offer a case example along with a demonstration of the use of a Case Summary Worksheet.
INTERNET BEHAVIOR DEPENDENCE DEFINED
A review of counseling literature reveals two basic definitions for Internet related disorders, both adapted from existing DSM-IV criteria for pathological gambling and substance dependence. We review these and propose a third, which we base on cognitive-behavioral criteria consistent with a developmental approach.
Goldberg presented the first definition for Internet-related disorders, Internet Addiction Disorder (IAD), as a behavioral addiction that serves as a coping mechanism and borrows from substance-dependence criteria from the DSM-IV (Garrison & Long, 1995, p. 20; Goldberg, 1996). Expanding the definition to include six "core components" of Internet addiction (salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), Griffiths (1998) hypothesized that the source of this addiction could stem from one or more aspects of Internet use such as the process of typing, the medium of communication, the lack of face-to-face contact, Internet content (e.g., pornography), or online social activities (chat rooms, MUDs, bulletin boards, computer games). Complementing this definition is Kandell's (1998) definition of Internet addiction as including any type of activity once logged on to the Internet. In short, most people agree that Internet addiction could have several sources.
Young presented a second definition for Internet related disorders, Problematic Internet Use (PIU), another diagnostic term based on DSM-IV criteria associated with pathological gambling (Young, 1996; Young & Rogers, 1998a). This definition requires that individuals meet five of eight criteria for Internet addiction in order to qualify as an addict. Criteria for Problematic Internet Use include (Young, 1999):
1. Preoccupation with Internet
2. Need for longer amounts of time online
3. Repeated attempts to reduce Internet use
4. Withdrawal when reducing Internet use
5. Time management issues
6. Environmental distress (family, school, work, friends)
7. Deception around time spent online
8. Mood modification through Internet use
By using criteria similar to that of pathological gambling, Young implies that PIU bears more similarity to an impulse control disorder than to substance dependency.
A problem with the use of these two definitions and their associated criteria is that they neither rule out co-morbidity as a causal factor (Mitchell, 2000; Shapira, Goldsmith, Keck, Khosla, & McElroy, 2000), nor separate the medium from the message (Griffiths, 1998; Pratarelli, Browne, & Johnson, 1999), nor determine whether time on the Internet is related to normal work or to pathological addiction (Kiernan, 1998). Of more concern to mental health counselors who prefer a developmental perspective, both presume pathological etiology and both lack a theoretical base (Grohol, 1999). To address some of these concerns, Davis (1999) proposes a cognitive-behavioral model for PIU. Extending Young's definition, Davis proposes that problematic Internet use be categorized as Specific Pathological Internet Use (SPIU) and Generalized Pathological Internet Use (GPIU). The first describes using the Internet to heighten the intensity of a pre-existing addiction (e.g., gambling or pornography), whereas the second describes using the Internet generally (e.g., chatting, browsing, etc). Davis extends Young's original definition of PIU, by addressing both the message verses the medium and co-morbidity, arguing that PIU may be activated by a pre-existing pathology and may then become a unique addiction.
We present a third term for Internet-related disorders, Internet Behavior Dependence (IBD). We believe that maladaptive Internet use can impair cognitive, behavioral, and affective functioning in an otherwise healthy person, and we specifically do not endorse a pathological etiology for this problem. In contrast to the first two definitions already discussed, we presume that excessive Internet use is a benign problem in living, that behaviors compensate for a lack of satisfaction in other areas of life, and that behaviors lie within the scope of the ordinary person to correct. In short, we see this disorder simply as a maladaptive cognitive coping style that can be modified through basic cognitive-behavioral intervention. Consistent with an addictions orientation, we expect Internet addicted people to demonstrate "dependence" criteria such as those outlined by Rasmussen (2000): failure to fulfill major role obligations at work, school or home; longer use with less enjoyment; restlessness, irritability, and anxiety when not using; extended use with unsuccessful attempts to cut down, control, or stop use; and continued use despite knowledge of physical, psychological, and social problems associated with excessive use. Our term, IBD, may be superior to previous definitions because it embraces a holistic and humanistic framework that complements our understanding of the client's world.
Regardless of what we call it, Internet-related disorders are emerging as a new problem for which clients desperately seek understanding, assistance, and change.
Research on the prevalence rate of IBD varies widely from study to study, with early studies reporting a prevalence rate of 40% to 80%, and recent studies citing lower rates of 6% to 14% (Brenner, 1997; Chou & Hsiao, 2000; Greenfield, 1999; Petrie & Gunn, 1998; Young, 1996). The difference in rates can be explained by the fact that the earlier studies were conducted online with self-selected samples mostly endorsing the category of "heavy users," whereas later studies used larger sample sizes with a range from light to heavy users. We embrace a conservative estimate of prevalence (6%) over the higher estimate, with the conviction that even 6% is worthy of concern and with the knowledge that less than 15% of Internet users spend more than 10 hours per week online. Researchers need to monitor prevalence rates, because Internet use and IBD will likely increase as this technology matures. In fact, a recent survey of 2,689 households found that weekly Internet use increased in direct proportion to access and to high-speed capacity (Benjamin & Ferraro, 1999; Nie & Erbring, 2000). Clearly, this is a problem of growing proportion and mental health counselors will want to be prepared to meet a growing demand for these services.
Age and education, but not gender or race, appear to influence the demographic profile of individuals with Internet Behavior Dependence. Changes in the availability and nature of Internet services appear to have eliminated gender and racial gaps for this population. Students and homemakers, however, remain particularly susceptible to this disorder.
IBD is typically found among those who are young or well-educated individuals. For example, a longitudinal study of the Internet use of 93 families found that teenagers in both White and minority families accessed the Internet more often than did their parents (Kraut et al., 1998), that older adults were less likely than younger populations to use the Internet (Nie & Erbring, 2000), that less than 11% of individuals 55+ use the Internet (Suler, 1998), and that older adults, even when controlling for time spent on the Internet, experience less distress than their younger counterparts from their Internet use (Brenner, 1997). Research supported the premise that IBD is likely to impact well-educated populations (U.S. Census, 1999). Numerous studies support this relationship, finding that excessive Internet users have an average of 15 years education (Brenner, 1997; Shapira et al., 2000; Young, 1996; Young & Rodgers, 1998a).
Current research failed to validate an earlier premise that men were more likely than women to experience IBD (Petrie & Gunn, 1998; Young, 1996). In fact, only 6% of the variance in Internet use can be explained by gender (Nie & Erbring, 2000), with women comprising approximately half of excessive Internet users in recent studies. While some researchers have hypothesized that high prevalence rates among women may be the result of men's unwillingness to self-report (Young, 1996; Petrie & Gunn, 1998), U.S. Census data indicates that these increases may be simply reflect overall increases in Internet use among women (U.S. Census, 1999).
Current research also failed to validate an earlier premise that Whites are more likely than minorities to experience IBD. As was noted earlier, Kraut et al. (1998) found no significant difference in Internet use among White and minority teenagers, a finding that was supported by Nie and Erbring's (2000), who found no significant racial differences in Internet use. A more recent study of 910 Taiwanese college students found a 13.7% prevalence rate for excessive Internet use, using Young's (1996) criteria for Problematic Internet Use.
Changing technological, economic, and business factors may account for the reduction of gender and race differences among excessive Internet users. These factors include (a) increasing ease-of-use for computer technologies, (b) decreasing costs for computer and Internet services, (c) increasing diversity among available Internet services, and (d) increasing social expectations for Internet use (Kandell, 1998). As Internet technologies become increasingly accessible and diverse, any unique demographic characteristics of IBD (such as age and education) are likely to disappear.
A Population of Special Concern
Unique psychological and environmental factors in the lives of college students may leave them disproportionately vulnerable to Internet addiction, especially where Internet use is a way to adapt or cope to overwhelming developmental stressors (Eppright, Allwood, Stern, & Theiss, 1999; Garrison & Long, 1995; Griffiths, 1998; Kandell, 1998; Young, 1996). Two major stressors include normal developmental tasks such as identity formation and the establishment of intimate relationships.
College students. Developmental stressors, coupled with free access to Internet services, may contribute to college student's vulnerability to Internet Behavior Dependence and may compromise their ability to negotiate tasks such as identity formation and building intimate relationships. Unlike "real world" relationships, online relationships provide a unique sense of anonymity, allowing students to develop relationships devoid of the anxiety found in face-to-face relationships (Kandell, 1998). Students can take on any persona they desire, without fear of judgment on appearance or personal mannerism, and can avoid racial and gender prejudice. These aspects of online relationships make the Internet an ideal forum for testing various relationship and identity styles (Griffiths, 1998; Young, 1997).
While using Internet technologies to cope with developmental stressors can been seen as adaptive behavior (Shotton, 1991; Griffiths, 1998), there is reason to believe that replacing real-world relationships with online relationships may result in poorer quality relationships as well as a diminished social capacity (Kandell, 1998; Kraut et al., 1998). College students who excessively use the Internet may be escaping from, rather than embracing, important developmental tasks, leaving themselves unprepared for real-world relationships. Two particularly maladaptive outcomes of college student Internet use include substituting face-to-face social contact with online social experiences and substituting identity formation with pseudo-identities online (Young, 1997).
College students who are vulnerable to IBD may find it increasingly difficult to cope with developmental tasks when they have university-provided free access to Internet services and when they are required to work in this medium (Kandell, 1998). Environmental and developmental elements, when combined, may make the Internet the "addiction of choice" for many college students.
Internet addicts can no longer be stereotyped as White, well-educated men with a thirst for knowledge (e.g. computer nerds). Current research indicates that Internet addicts can be of any race or gender. They will generally fall between the ages of 18 and 55, with an average of 15 years of education. In addition, it appears that many individuals become addicted for social rather than intellectual reasons. As technologies become increasingly accessible and diverse, age and education will no longer serve as useful guidelines for examining Internet addiction.
When assessing for Internet addiction, mental health counselors may profit from examining four key areas: Internet usage, usage content, environmental distress, and co-morbidity. In addition, mental health counselors should be aware of inventories that have been developed for the assessment of Internet addiction.
Accurate assessment of actual Internet use is difficult to determine because of underreporting of hours spent on the Internet, either because of denial or because of losing track of time while using (Young & Rodgers, 1998a). One way to get a clearer picture of the problem of Internet use is to interview not only the individual user, but also his or her significant others, including sympathetic co-workers. Regarding problematic use, studies indicate that significant social, vocational, and financial distress can occur if Internet usage exceeds 20 to 25 hours per week (Brenner, 1997; Chou & Hsiao, 2000; Shapira et al., 2000). Nondependent users average 2.5 to 5 hours of Internet use per week (Chou & Hsiao, 2000; Davis, Smith, Rodrigue, & Pulvers, 1999; Kraut et al., 1998; Average web usage, 2001; Nie & Erbring, 2000). Internet-dependent individuals average 8 to 40 hours per week (Chou & Hsiao, 2000; Davis et al., 1999; Young 1996). Nie and Erbring (2000) found a positive correlation between the number of years online and the number of hours spent online. To repeat, accurate assessment of use may require family or co-worker feedback to bypass potential denial where a real problem may exist.
Significant differences exist in the types of content accessed by Internet dependents and nondependents. People who are Internet dependent spend the majority of their time online engaged in social activities such as participating in newsgroups, chat rooms, MUDs, and bulletin boards. People who are nondependent tend to spend the majority of their time in web browsing and communications through email. A key difference between dependent and nondependent use of the Internet is that addicts use the Internet to engage in new relationships whereas nonaddicts use the Internet to maintain existing relationships. (Chou & Hsiao, 2000; Young, 1996).
Internet dependents generally experience distress in at least one of five areas: social, vocational, educational, financial, and physical. In the past, financial distress has been related to online fees. However, with the virtual elimination of hourly fees for online services, this type of distress is unlikely to be found in current populations (unless it is related to vocational distress). Distress almost always occurs as a result of the dependent neglecting some aspect of his life in favor of online activities.
Research indicates that Internet addiction is often associated with other forms of mental distress such as depression, impulse control disorder, low self-esteem (Armstrong et al., 2000; Petrie & Gunn, 1998; Young & Rodgers, 1998b). Shapira et al. (2000) found a 100% incidence rate of Impulse Control Disorder (ICD) in their sampling of Internet addictions, and a relatively low rate of Obsessive Control Disorder (15%). While these findings in no way establish causation for Internet Behavior Dependence, mental health counselors will want to assess for ICD.
Internet Addiction Assessment Tools
Although reliability and validity issues abound in the use of Internet addiction assessment tools, some rudimentary attempts to assess addiction do exist. These fledgling assessment instruments include: Brenner's (1997) Internet-Related Addictive Behavior Inventory (IRABI), the CIRABI-II (Chou & Hsiao, 2000), the Internet Usage Survey (Armstrong et al., 2000), and Young's DQ Assessment tool (Young, 1997). These instruments must be used with caution until future research establishes their validity and reliability.
There are clinical criteria for determining Internet "abuse" or "dependence." Similar to persons with chemical and nonchemical addictive disorders, Internet addicts describe their abuse or dependence behaviors in the following way (Rasmussen, 2000):
* They find it increasingly difficult to meet their major obligations at work, school, or home.
* They use longer, with less enjoyment.
* They are restless, irritable, and anxious when not using.
* They do not succeed in cutting down, controlling, or stopping use.
* They experience physical, psychological, and social problems due to their use, yet they persist in their Internet behavior.
Although mental health counselors have been aware of problems associated with Internet use since the late 1990s, research on Internet use and abuse has lagged behind practice. Internet addiction was evident at the 1999 annual meeting of the American Psychological Association when Greenfield suggested that as many as 6% of Internet users may suffer negative outcomes such as marital disruption, decreased school performance, increased financial expenditures on Internet shopping, or illegal activity (Donn, 1999). With college populations the incidence of abuse is as high as 10% (Yang, 2000).
Addiction includes both chemical and nonchemical addiction disorders. Mental health counselors already know much about working with people who are nonchemically addicted to behaviors such as pathological gambling, compulsive shopping, excessive expressions of sex and love, and over- or under-eating. It is time to update our clinical knowledge and practice to include working with people who compulsively surf the Internet. Nonchemical addiction behaviors, like chemical addiction behaviors, share similar profiles of etiology, expression, and response to treatment (Rasmussen, 2000). Three treatment modalities in particular show some promise: cognitive behavioral therapy, a 12-step addiction program, and expressive arts therapy (Yang, 2000). In addition to models of intervention, Dr. Kimberly S. Young offers a self-help guide in her book, Caught in the Net (1998). In this article, we confine our contribution to one of applying Cognitive Therapy to Internet addiction for two reasons: it is classic, and it is accessible without immediate additional training.
COGNITIVE THERAPY AND INTERNET ADDICTION
Mental health counselors have a strong desire to learn how to do interventions that address human suffering of all kinds, including that of Internet addiction. Already knowledgeable of both conceptualization and techniques associated with cognitive therapy, mental health counselors can readily apply cognitive therapy to their work with persons addicted to the Internet, once provided with a conceptual model. Because we realize that cognitive therapy is more than a set of techniques, and incorporates the role of emotions and the therapeutic alliance into a working paradigm for people wanting change, we think it is the appropriate method for working with the complex dynamics associated with problem Internet use. What follows in this section is an example of the use of a Case Summary Worksheet that is recommended for Cognitive Therapy (Beck, 1995), adapted for use with people presenting with Internet addiction. For a tutorial in the Cognitive Therapy method, see Judith Beck's (1995) book, Cognitive Therapy: Basics and Beyond. We begin our case example at the point where the mental health counselor would summarize the case of Becky, using the Case Summary Worksheet, found in this same book.
Becky began using the Internet when she was a seventh-grader after her parents bought her a computer for Christmas. At about age 15, she began creating web pages for her high school. Her parents divorced when she was 16, and she began to isolate herself in her room to join chat groups with other teenagers whose parents had divorced. She felt that these contacts were more genuine than those of even her closest high school friends, because she could feel "really free" to say what she deeply felt without fear of rejection. Soon, she began spending most of her available free time with her online friends, preferring her time with them to her time with her school friends. Her time online escalated at the expense not only of her friends, but also of her schoolwork as well. After she began failing in three subjects, her mother threatened to get rid of the computer. Becky convinced her mother that she would "just die" if she could not connect with her online friends and promised to improve. Becky's mother began dating and found it convenient to rationalize her daughter's time on the computer, since Becky did not seem to mind her mother's increasing absence. Becky's time online increased to the point that she began faking illness so that she could remain at home and avoid school. In spite of earnest New Years' resolutions to quit, Becky continued her Internet use. The years passed. Her mother re-married. The crisis came when the guidance counselor informed her mother that she was in danger of not graduating with her senior class. At this point, the mother and daughter, desperate, contacted a mental health counselor. Although they achieved some success, enough to allow Becky to graduate high school, she continued to miss her contact with her online friends and began to gradually escalate use once the graduation crisis had passed. To reward Becky for her graduating and to bolster her ability to complete her college term papers, her parents bought her a laptop computer as a graduation present. Since then, Becky has secretly increased her Internet use to the point that she is in danger of failing her first semester of college. At this point, she voluntarily seeks counseling with a community mental health counselor.
Now, using the Case Summary Worksheet, the mental health counselor can proceed in this case, using Cognitive Therapy, as suggested in the following paragraphs.
USE OF CASE SUMMARY WORKSHEET WITH INTERNET ADDICTION
General Information, Identifying Information
The mental health counselor would write his or her name, Becky's name, and date of case conceptualization on the Case Summary Worksheet. Included in this section would be any relevant identifying information. In our example, the client is an 18-year old Caucasian female freshman living in a dorm with three suitemates.
The diagnoses, using the DSM-IV classification system would appear as follows:
* Axis I: Depressive Disorder NOS, single episode, mild, 311
* Axis II: No personality disorder
* Axis III: No physical disorders or conditions
* Axis IV: Severity of psychosocial stressors: moderate (leaving home for first time, feeling guilty about increased Internet use)
* Axis V: Global assessment of functioning: current 70; past year 80
Here the mental health counselor would list the results of any testing that is relevant to this case, such as those associated with Internet addiction that were referenced earlier in this manuscript (IRABI, C-IRABIII, the Internet Assessment Survey, and the DQ Assessment Tool). General trends of these scores would be noted in this section of the Worksheet. In this case, the Beck Depression Inventory is recommended.
Presenting Problems and Current Functioning
Becky complains of anxiety, social withdrawal, decreased sleep, missing classes, inability to decrease her time on the Internet despite its negative impact on her friendships and despite her lying to her mother about her Internet use. Recently her problems with her suitemates increased as Becky has decreased her interest in going out with them, preferring to stay and use the Internet. Becky also reports a significant increase in her irritability with her friends who encourage her to get out more.
Historically, Becky is the only daughter of parents who divorced when she was in high school. Always popular in grade school and junior high, and always an excellent student until she began using the Internet to cope with her parent's divorce, Becky experienced normal development with no medical problems, no prior psychiatric history, but with no dating history. Relationships with her mother and father were remote following the divorce as her father became clinically depressed and began using alcohol and as her mother began dating and later remarrying. Significant events and traumas other than the divorce were that her father became an alcoholic, lost his job, and is now in recovery.
The cognitive model as applied to this client includes an analysis of: (a) typical current problems/problematic situations and (b) typical automatic thoughts, affect, and behaviors in these situations. In addition, it is necessary to look at her core beliefs, her conditional beliefs, and rules (shoulds/musts applied to self/others).
Typical current problems/problematic situations: Becky is having increasing difficulty in studying and writing her papers for class; in desiring to be social; in cutting back on her Internet use; in feeling confident enough to date; in feeling estranged from her mother due to her secrecy surrounding the actual time spent online in chat rooms.
Typical automatic thoughts, affect, and behaviors in these situations: Becky thinks she can never break her Internet habit; she thinks she is a failure; she thinks she will eventually fail her first semester courses; she feels sad. She is worried that she will flunk her tests and does not trust herself to pull herself away from the computer to study; she feels anxious. She thinks that she should be a better daughter, and that she is letting her mother down and acting like her father; she feels guilty.
Core beliefs: Becky thinks that she is like her father and is an addict; as such, she feels inadequate and incompetent.
Conditional beliefs: Becky thinks that if she cannot reduce her Internet behavior, she will flunk out of college. She thinks that if she fails in school she has failed in life and will become a miserable parent like her depressed, alcoholic father. If that happens, she thinks she might take her life. She worries that if she asks for help, it will be apparent to everyone that she is weak.
Rules (shoulds/musts applied to self/others): Becky believes that she must prove that she is better than her father, that she must live up to her potential, that she must excel, in order for life to be worth living.
Integration and Conceptualization of Cognitive and Developmental Profiles
In this section of the Case Summary Worksheet, the Cognitive Therapy model looks at Becky's self-concept, the interaction of life events and cognitive vulnerabilities, compensatory and coping strategies, and development and maintenance of current Internet addiction disorder.
Formulation of self-concept and concepts of others: Becky sees herself as competent at most things when she is not using the Internet, but at few things when she is heavily using the online chat rooms. She overestimates her mother's strengths and wishes she could be like her mother.
Interaction of life events and cognitive vulnerabilities: Becky has always been shy, and finds it difficult to initiate interactions with others, although she was always well liked by her peers until recently. Her father's inability to cope with the divorce after several years has reinforced her belief that she is weak also. She would like to be like her mother but fears she is more her father's daughter.
Compensatory and coping strategies: Becky holds high expectations for herself, and works very hard academically to make up for her lapses; she escapes into the world of virtual friends until a crisis in school propels her into action to save her academic life. Most of the time, she can save herself academically, but those times are becoming fewer as she re-enters her virtual world. She avoids seeking help.
Development and maintenance of current disorder: Becky's relapse with her Internet use coincides with her development crisis of having to make new friends in a new environment, without much parental support. Anxiety probably propelled her to ever-increasing Internet activity as an escape from her social and academic challenges. Then Becky became quite self-critical and upset about her inability to refrain from Internet use. As she became more engaged with her online friends, she became less connected to her mother and her friends at college. The lack of positive encouragement may be contributing to her rare and fleeting thoughts of suicide.
Implications for Therapy
This section looks at the suitability of cognitive interventions, Becky's personality organization (sociotropic versus autonomous), her motivation, goals and expectations for therapy, therapist's goals, and predicted difficulties and modifications of standard cognitive therapy.
* Psychological mindedness: high
* Objectivity: medium/low
* Awareness: medium/high
* Belief in cognitive model: high
* Accessibility and plasticity of automatic thoughts and beliefs: medium
* Adaptiveness: medium
* Humor: low
Personality organization--sociotropic versus autonomous: Becky is higher in autonomy (self-oriented) than sociotropy (socially-oriented). She places a high value on achievement, sees asking for help as a weakness. Becky is low in sociotropy; her orientation is now one of concern about how others view her, but not enough to exert her to place a higher value on her college friends and roommates over her on-line friends.
Becky's motivation, goals, and expectations for therapy: Becky is very motivated, has some expectations of therapy due to her past positive experience with her counselor in high school. Becky especially likes the idea of becoming her own therapist.
Goals: Improve grades, decrease worry of becoming her father; avoid disappointing her mother; wean herself off the Internet to the point that it enhances her life rather than controls her life.
Therapist's goals: Decrease self-criticism; promote individual identity separate from her father; teach basic cognitive tools; decrease time on Internet; do problem solving around studying, papers, tests; decrease personal isolation and increase self-efficacy related to social relationships.
Predicted difficulties and modifications of standard cognitive therapy: None.
In sum, the use of the Case Summary Worksheet is an inductive way to illustrate how a mental health counselor can work with a client who is dependent on the Internet to the exclusion of normal developmental tasks and foci, using classical Cognitive Therapy.
Treating nonchemical addictions is similar to treating chemical addictions: assess, diagnose, plan treatment, intervene, and evaluate the effectiveness of method. The treatment method illustrated in this article-Cognitive Therapy--is ideal because most mental health counselors already know how to do cognitive therapy generally. Applying Cognitive Therapy to Internet Behavior Dependence is a familiar and natural way to counsel people. We hope this example will encourage mental health counselors to have confidence in treating people suffering with this emerging, complex, and compelling disorder.
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Alex S. Hall, Ph.D., is a an assistant professor and Jeffrey Parsons is a graduate student. Both are in the Counseling, Rehabilitation, and Student Development Department, University of Iowa, Iowa City. Email firstname.lastname@example.org.