Chattanooga Times Free Press features reporter Casey Phillips spoke with psychiatrist Hilarie Cash, co-founder of reSTART, the country's only in-patient video game addiction recovery program, about how game developers build addictive qualities into their titles, the effects of addiction and why college is so dangerous for potential addicts.
CP: What was the impetus for founding reSTART?
HC: I've actually been interested in developing my expertise in internet addiction for 15 years. In 1999, I founded a company called Internet/Computer Addiction Services. There, we offer out patient services. As it evolved, our main focus ended up being on sex addiction, so we have a program called No More Secrets, for sex addicts and their partners.
I, however, also maintained a keen interest in the problem of video game addiction. Although we were never able to get a huge program going, I've been doing this work on a case-by-case basis for years. For at least 10 years, I've been aware and very frustrated with the lack of in-patient services because you can get so much more done if someone goes in-patient.
In '08, Kim McDaniel and I co-authored a book called, "Video Games and Your Kids: How Parents Stay in Control" because we had so many parents we were working with who didn't know what to do with their game-addicted kids.
It's been a long time coming, but I never had the wherewithal to do it. Then, when I met (reSTART executive director) Cosette (Dawna Rae), she had opened a private practice and was working with one family in particular that was her motivation to contact me so we could discuss the issues surrounding treating internet and video game addiction. I expressed my frustration with the lack of in-patient services that were reasonably priced and were devoted specifically to this problem.
We just put out heads together. She had a home on five acres of land that she and her husband had been discussing an idea of turning into a retreat center. The light bulb went off. She really had the property to do it and the expertise as well, so this was born.
CP: In general, how serious a problem is video game addiction?
HC: It's a very serious problem and one that is growing. With the generations that are coming up behind who are, from a very young age being exposed to video games and computers and the Internet in general, it's going to be an ever-increasing problem. The reason is that they're getting wired at a very young age to being completely comfortable with that technology, and in the case of some kids, to be more comfortable in the cyber world than they are in the real world. It's a serious problem.
(Harris Research) said that about 8.5 percent of kids between 8-18 fit the criteria for video game addiction. I think the numbers are pretty consistent that way. Among the players of MMORPG's, the level of addiction among those players is probably much higher.
CP: Is this just an issue among kids or can adults become addicted as well?
HC: Oh absolutely. Our center is set up for adults only, so we only take ages 18 and older. What very typically happens is that you have a kid at home who spends a fair amount of time playing video games, but the parents have been constantly, through whatever means, providing the structure that allows them to still get on with life and graduate from high school. Then, they go off to college, and in college, they've lost that family structure. They didn't internalize limits, they were reliant on their parents, and suddenly they're free. That's when a lot of young adults start getting into trouble.
In college, these young adults have spent a lot of time on the Internet playing video games in their childhood and teenage years, and there are lots of skills they really haven't developed well. Those are things like learning to manage emotion, anger and fear and so forth, and many of them haven't developed good social skills. Also, their attention span is not very well developed. They have problems staying focused.
If they go off to college, the academic demands are usually higher than in high school, and you need skills, both academic skills (paying close attention), social skills and emotional management skills to see success in college.
What we're seeing is a problem that is growing through childhood but doesn't come to real fruition for a certain number of young adults until they leave to go to college.
CP: So there's a whole generation of future video game addicts in incubation right now as children?
HC: I think so. I hope I'll be proven wrong, but I haven't been proven wrong yet. (Laughs.)
Because I got interested in this early, 15-16 years ago, I've been able to have a sense of the trends and the way things are going. I've been predicting a lot of the things we're seeing now. The people who are developing video games are very sophisticated now about behavioral principles. They want to get gamers hooked, and some of the companies really want to go in the direction of developing games that are subscription games. They want people who are hooked on those games.
"World of Warcraft" was a masterpiece of this. Game developers know perfectly well what they're doing, and for them, it's good business to create a highly addictive game. As time goes by, they're trying to make it ubiquitous.
Microsoft has just announced that they've come out with technology that allows gamers to game at home on a console or a computer and continue to game, uninterrupted, on their phones. There's no reason why they would ever have to stop. They can take it with them wherever they go.
The folks who are delivering this are always thinking about how to make it more available, more ubiquitous, more addictive. They're developing implants for the brain. They have visions of people not even having to use this inconvenient devices that hold in their hand and get carpal tunnel syndrome with to game. They're creating body suits that can stimulate the whole body. It would obviously be even more immersive if you're wearing a suit that gives you the physical sensation of what you're doing in the game. The more immersive these worlds become, the more addictive they also become.
CP: What are some of the primary culprits for encouraging addictive habits?
HC: I can't even keep track of all the games my clients are playing. I know that "Halo" and "Counterstrike" have been highly addictive, especially "Halo." "Counterstrike" is something many of my clients have been addicted to. "Call of Duty." These are all games my clients talk about.
In general, the rule is that if the game has a persistent universe, and it's online, and it's massively multiplayer with any sort of interesting storyline to it and decent graphics, it's much more likely to be a game that will draw players in in an addictive way. That's because there's no end, and the layers are multiple and the social aspect of it is enormously important.
CP: Many gamers would argue that gaming doesn't harm their social skills, that these massively multiplayer games are a chance for them to have their social interactions, just in a different context.
HC: Absolutely. The addicted gamers almost always say that, that that's where their friends and their social life is. If it were just a good substitute for a real-world relationship, I wouldn't have a leg to stand on. I think the reality is, it's not an adequate substitute for real life social relationships.
Here's an important reason why. I'll refer you to a wonderful book called "A General Theory of Love." It's a book about attachment, and the role of attachment in human evolution and well-being.
Attachment happens through something called limbic resonance, which happens when we are in the presence of others we care about and feel safe with. We require limbic resonance in the search to be well regulated, both physiologically and psychologically. It's essential to our well-being.
Do we get limbic resonance when we are interacting socially in cyber space? That's a critical question. Ultimately, it's a research question. The research that has been done so far suggests that we don't. There are a number of studies that have shown a correlation between the amount of time spent in cyber space and depression.
The reason I think this correlation exists is because we're social animals. We are animals, and as animals, we use our senses, and these need to be stimulated in the presence of people we care about.
That does not happen in cyber space to the degree it happens in the real world, and we just need it. Those who are developing the cyber universes, if they can show that they can have that happening to you, then maybe we can say it's an adequate substitute.
The trouble is, you have to leave that world and come into the real world to live and function and work and have a family and have relationships.
So far, these people who are spending inordinate amounts of time in cyber space are not developing well. In fact, I've talked to a number of people who have lost the social skills they had before becoming addicted to "World of Warcraft."
At least at this stage of the game, we need to spend plenty of time in the real world and be in real world relationships. That means not being lonely and bored in the real world, but having meaningful life with meaningful relationships in the real world.
We can have entertainment as a part of our lives, but the way to have that integrated needs to be in a balanced way. I'm not saying there's anything wrong with video games or any part of the cyber experience. The trouble is when it's out of balance.
CP: What are some tests you use to determine gaming addiction? Is it a matter of raw amount of time spent playing in a given period or are there other criteria you look for? s
HC: No, you definitely can't go based on time spent online, although there are some cases that are common sense. If you're spending 17 hours a day playing "World of Warcraft," you're not getting anything else done, including getting enough sleep. So that's obvious.
If you go to our site (www.netaddictionrecovery.com), you can find all the signs and symptoms of internet addiction.
You have to meet criteria for internet addiction. The interesting question, and the pertinent question, is how much time spent playing video games is correlated with those signs and symptoms. That's not been completely established.
Kimberley Young did research in the mid-'90s. She did the first broad piece of research in this area, and she found that people who spend more than two hours of time a day on average in personal time online started to show signs of addiction. Dr. Tao Ran's research suggests that more than four hours a day spent in video gaming and personal time on the Internet. I think we don't know, but we look first for the signs and symptoms. When somebody comes to us, we do an in-depth interview and look at the ways their lives are not working well.
CP: How serious a condition is video game addiction considered within the psychiatric community?
HC: The American Psychiatric Association are the folks who put together the DSM, the Diagnostic Statistical Manual, which conditions you to make diagnoses. Whenever something makes it into the DSM, it is then legitimate in the eyes of the whole world.
For the first time, they're working on the DSM 5, a new revision, and they have, for the first time, recognized that there can be behavioral addictions. This is significant.
They are a conservative body and require a great deal of convincing. They are convinced that gambling is an addiction. Back in the '50s, by the way, they were not even convinced that alcohol was a form of addiction. They are a conservative body, and it takes them a while to catch up, but they're catching up to the idea that gambling is an addiction.
We have tried to convince them that Internet addiction needs to be considered also as a legitimate addiction. I don't know if we will succeed. This is such a new phenomenon. There's lots of research being done now on it, but it takes time to build into something weighty enough to convince them. We don't know, but we're doing our best to do research and gather it so we can convince them.
Once that happens, nobody will argue over whether it's an addiction. Right now, many, many, many people in the medical field argue that it's not a true addiction. They argue that it's a symptom of something else, a symptom of anxiety or of stress or depression. Those who think of it that way, all they want to do is treat the depression, the anxiety or whatever. Their assumption is that if you treat that stuff, the addiction will go away.
Sometimes, that does work, but often times, it doesn't work because just as with alcoholism or any other addiction, you have to stop the behavior to effectively treat whatever underlies it. I'm always getting on a soap box with my colleagues about this. They're seeing the problem. Lots of people come into their offices who are suffering from the problem, it's just that they often don't treat it the way I think it needs to be treated, which is as an addiction, first and foremost.
CP: Does a video game or internet addiction manifest itself in the same way as a substance abuse addiction? Is there such a thing as video game withdrawal?
HC: The signs and symptoms are quite similar. There are some symptoms that are more particular to internet addiction, like poor social skills. Many people who are drug or alcohol addicts actually have a lot better social skills than internet addicts because they're hanging out in bars talking to each other or at parties getting high. In terms of what's happening in the brain, however, it's fundamentally the same thing, whether it's a behavioral addiction or a substance addiction.
With some substances, just have a far more physical withdrawal for many substances because of adaptations the body develops to the drug itself. There are definitely withdrawal symptoms. Those symptoms that I hear about tend to be agitation, anxiety, depression, irritability, queasiness in the stomach, shakiness and difficulty sleeping. They're not severe the way it would be with a serious alcoholic.
There's often rage, but I think the rage is more about, "Don't take my drug away from me," protecting their source. When parents go in and haul out the computer, there are many cases of kids who run into the kitchen to grab a knife, punch holes in the wall, yell and scream and threaten their parents. I wouldn't exactly call that withdrawal because withdrawal hasn't begun yet. It's about wanting to protect access to their drug of choice.
CP: You've been studying video game addiction for about 15 years. That's around the time that "Everquest" came out. Is that when gaming addiction started becoming a problem? Was it an issue before massively multiplayer titles became popular?
HC: It was. My very first online gamer addict came to me 16 years ago. He was addicted to a Dungeons & Dragons text-only multi-user dungeon. Even though it didn't have graphics, he was classically addicted to it.
Yes, once "Everquest" came, that really ratcheted things up. "Everquest" was the first pretty popular, highly addictive massively multiplayer game a lot of people were playing.
CP: You mentioned "World of Warcraft" by name as a textbook case of a game with addictive qualities. What is it that makes you point to it as a prime example?
HC: It's just mind blowing. All these games, first of all, appeal to us because of something called intermittent reinforcement, which is a behavioral principle (B.F.) Skinner discovered 100 years ago in his studies of rats and pigeons. He discovered that you will work very long and very hard for a reward, if the reward is not predictable and comes frequently enough. It's sort of the unpredictability of reward. The games are built that way, and they're many are built so you experience reward more frequently early on and then have to persist in, often very boring, elements of the game to keep getting the reward. By then, you're hooked. That's the same principle on which gambling works.
That's fundamental, but then there are these multiple other layers.
Certainly, the social aspects of the game is critical. If you're a young person who wants to be esteemed by peers, you enjoy competition and cooperation and you want to feel important and valued, all of these things are more readily available, more easily obtained in the game, than in real life. How often are you able to be a healer or a leader of a guild in real life? Not often. That's a tough thing to achieve, but you can achieve that, without too much difficulty, if you put in enough time in a game like "World of Warcraft." If you're esteemed within your guild and your guild is esteemed in the universe, all of this is very heady stuff. That's another huge level of reward.
Many of us really love the idea of being heroic. I think there's a strong psychological draw to feeling heroic. Games like "World of Warcraft" appeal to that instinct or that psychological need.
Also, the graphics are interesting, for people who like those graphics. I myself am not particularly enamored with them, but I didn't grow up with them. If I grew up around them, I'd find them, I'm sure, very appealing.
Many of these games have storylines that seem interesting or have the ability to create an interesting storyline for yourself and your guild buddies.
The ability to be who you just are not in the real world, to explore aspects of yourself, in these games is a draw. In these games, you can play completely anonymously, so you can pretend to be something other than what you present yourself as in the real world. You can be a different gender or a different species. You can be aggressive when, in the real world, you're timid. There's great freedom in that, and that's very rewarding, getting to experience different aspects of yourself that you are normally too inhibited to experience in the real world.
Then, there are games like "Second Life," which also have a strong sexual component to it. Romantic sex addiction is rampant in games like "Second Life." That's a whole other rewarding element, the sexual stimulation of that. Plenty of people also experience that romantic/sexual element playing "World of Warcraft" because they start having online romances with people they meet in the game.
There's also a whole financial element. It's an urban legend that if you level your character up that you can sell it off for big bucks. Some people do. If they divide their time by how long they've been playing, though, they're working for pennies. But it's still cool to think, "Wow, I can level my character up, and people will actually want to buy it from me."
CP: Do your patients usually hit a critical moment when something drastic happens before they come see you or do they seek treatment early on in their addiction?
HC: (Laughs.) No, that never happens. That's not entirely true, actually. My first client, Ben, had reached critical mass, but he was willing to admit that it reached a critical mass, went to his parents and said, "I need help." More often, what happens is that they are full of shame and they don't realize what's going on until something really bad happens, like their wife is divorcing them or whatever.
Parents will sometimes want to intervene before it's a complete fiasco for their kids. Always, the earlier parents come, the more success they'll have in making a wonderful difference in their kids' lives. Often, they come when their kids are in high school and are already starting to fail out. All that depends on what age the kid is, what kind of relationship they have with their parents and how functional or dysfunctional the family is. All these are factors that will play into the success of the intervention.
In general, people come way too late.
CP: Is stopping cold turkey a good idea or is it better to simply try and wean oneself off gaming?
HC: I am an advocate of going cold turkey, under the right circumstances, because it really gets the job done efficiently. That's why when someone comes to reSTART, they go cold turkey. They're coming for 45 days without access to the Internet or gaming technology. They really can go through a lot of transformative experiences because they are away for so long. They're working on themselves, understanding themselves better and developing skills they lack. When they leave, they still need ongoing therapeutic intervention, but at least, it really moves them forward enormously.
If you've got someone who's not going cold turkey and is on a weaning down process, there are a couple of problems with it. One is that it's just plain old difficult. We're talking about a family where the addict is living at home.
It's hard for parents to be effective. Kids are amazingly resourceful in getting around whatever limits the parents are setting. Many parents are also scared of going cold turkey. We've often worked with families where parents have been ineffective for years because they've been afraid to get rid of the computer. Sometimes, that's because they're afraid of what will happen to the kids, and sometimes, the parents just don't want to give up the computer for their own convenience.
That's a bad situation because then you have a kid who's been learning how to get around their parents to satisfy their addiction for years. They've developed a lot of really nasty habits, lying and deceitful behavior, in getting around their parents ineffective limit setting. So, that's not good.
Ken Woo is a psychologist in California who has developed a hardware device that can be put on a PC. That's a fabulous device called a PC Moderator. It gets locked on the computer, and it comes with a protocol for how to wean your game addicted kid week by week by slowly limiting the amount of time. The device will cause the computer to shut off after the set amount of gaming time has lapsed. That's a wonderful resource for parents who want to do it gently by weaning down.
CP: Is gaming addiction treatable at home or does it require professional intervention, in most cases?
HC: You have to think about it like any other addiction. There are alcoholics who drop their drinking. There are coke addicts who stop using cocaine and pot heads who stop using weed on their own without going into therapy for treatment. It's not easy to do, but it happens, for sure.
All those chemical addicts have the advantage that internet addicts don't have, which is that they can go to 90 meetings in 90 days and do a 12-step program. They can get a sponsor and can work steps. It's a kind of therapy, just not with a professional.
They have that advantage. We have a 12-step program called Internet and Technology Addicts Anonymous and Online Gamers Anonymous. People can start 12-step programs using either our IPAA format or the OLGA format, but it's pioneering stuff, so it's much harder to get it going and get started.
So can people quit? Absolutely - maybe. But it's tough. That's the nature of addiction. It's very hard to stop.