addictions, and more specifically MMOG addiction, have been hot button
topics for several years now. From prime time news stories on
“investigative journalism” shows to our own
articles here at Ten Ton
Hammer, the problem has been examined from nearly every angle. With the
growing number of gamers and the increased visibility of this type of
addiction it seems a foregone conclusion that we would begin to see
specialty clinics pop up to treat folks who are struggling to control
their play time.
Polish gaming website href="http://mmozin.pl">MMOZin
has tracked down just such a clinic, href="http://www.netaddictionrecovery.com/" target="_blank">reSTART
Internet Addiction Recovery Program,
and were able to sit down and speak to its director, Dr. Hilarie Cash.
We have partnered with them to bring an English language version of the
story to you, thanks to MMOZin writers"Achilles" and "Kroliczek"for
this fascinating interview.
THE CLINIC AND HISTORY
Hello. Can you
tell us a few words about yourself and your role in the reSTART clinic?
Hilarie Cash: style="font-size: 12pt; font-family: "Times New Roman";">Hello.
I am the co-founder of the clinic and we started it just this summer. I
have been developing my work with internet addicts since 1994 when I
met my first video game addict. 11 years ago I co-founded an outpatient
clinic called Internet/Computer Addiction Services and last year I
co-authored a book called style="font-style: italic;">Video Games and Your
Kids: How Parents Stay in Control.
So how did you
meet your first game addict?
Cash: He came to my office
when I first moved to the Seattle area. He was one of my early clients
and he was depressed; his marriage was falling apart. As we worked
together it became clear that he was addicted to an early style="font-style: italic;">Dungeons & Dragons
game--text only, no graphics. But he was classically addicted. He had
lost 2 jobs because he could not stop playing and he eventually lost
his marriage as well.
Can you tell us something about the clinic itself? Where it's located?
How many patients you have now and how many a year? How long does the
Sure. The clinic started just at the end of July 2009, so we are
relatively new. We have had four clients: three young men and a woman
in her thirties. They have all finished and we are on a break until the
New Year. It's located in Redmond, Washington which is the home of
Microsoft. When people come, they come for 45 days. It is only for
adults; patients must be 18 or older. When they first come, they come
for a minimum 2 days to be interviewed and to interview us, because we
don't want anyone there who doesn't want to be there. So if they decide
they want to be there then they stay for 45 days or longer if they
choose. During that time they don't have access to the internet. The
idea is that it takes at least 30 days for the brain to make some
adjustments it needs to make to get over this addiction, so the brain
can begin to rewire back to normal. During that time we are helping
them look at why they got addicted, what
motivated their addiction and we're assessing to see what skills they
are lacking so they can be successful in their adult lives. We try to
make a good start at helping to build those skills. It is a
multi-faceted approach. They live on a regular, daily routine of waking
up at a normal hour, having breakfast, cleaning up, then after
breakfast doing chores in the house and on the property with the
animals and in the garden. After that they have psychotherapy and
education related to their addiction and the skills they need to
develop. Then it's lunch, and after it is group psychotherapy and life
skills coaching. Then it is time for them to work with Cossetes
husband, Gary, who is in construction. They help him with building
projects on the property.
The girl also?
No, she had art projects. She didn't want to work outside so she was
able to do work on them - she's an artist. In the evening people come
together and there are responsibilities that are shared for preparing
the evening meal--cooking planning, all of that. There's also
meditation training and one twelve-step meeting during the day on
Monday and another in the evening on Friday. Then it's free time for
the rest of the evening.
The addicts, and in particular most of
our clients, will be like the young men we’ve seen so far,
who were 18,
19, and 25. They will be behind in social skills, because their social
lives have been lived online and not in real life. So, the idea of all
these structured activities is to help them develop social skills and
begin to address the lack of just simple daily skills that they need to
develop if they're going to take care of themselves independently as
adults--taking care of their personal hygiene, learning to cook, clean
up their physical space and just being adults in the real world. We
find that they generally are not good at that. And then, we start to
look at psychological factors they need. Sometimes they're on
medication for depression, anxiety, or ADD.
You have a doctor
We work with a doctor in Redmond that they can visit. They sometimes
choose to go off medication, or they can stay on medication, or they
might need medication for the first time. What I have certainly found
over the years is that depression and anxiety and even Attention
Deficit Disorder are conditions that are sometimes brought on by some
spending too much time online and playing video games. When they get a
break from that and begin to engage with life and begin to develop the
skills to feel successful in life, the depression and anxiety begin to
lift and go away without the medication.
Do you think that the addicted person can help himself or
or is it that kind of addiction that really needs help from
Cash: I think it
depends. There are people who are capable of recognizing that they seem
to have an addiction and they pull back and cut down the amount of time
they're spending online or take a fast and stay away from it for a
while. There are definitely people like that, and many can do that in
fact, but there are some who can't, who are so deep into their
addiction they have lost all the control and seem powerless and those
people need to seek professional help.
I want to say one more
thing: if the person is young enough and living at home, the problem
can usually be handled pretty easily once the parents understand how to
set appropriate limits and are effective in that. Once parents can
structure their lives in a way to regain control over the computer and
that technology, and if the kid is young enough that they will listen
to parents even if they are mad, it works very well. If I have parents
of younger teenagers I only work with the parents; I don't worry about
working with the kids usually.
MMOZin: But these teenagers are still minors? Or are they adults?
When I work with a family I'm working with minors. When they come to me
at reSTART we're working with adults.
average age of an addicted player?
Well, I'm not sure. The people who come, that I see, are almost always
between the ages 18 and 30. There are certainly people older that are
addicted as well.
as I understand it there are more boys addicted than girls usually?
Cash: I think that if you
take the internet as a whole and include social networking and shopping
and other activities it’s pretty even in terms of addiction.
comes to the MMOs it's far more boys than girls.
When we are
talking about MMOs or other games, but I think MMOs mostly, are there
addicted players identifying themselves with their virtual identities
when they come to you, or is it an addiction like spending too much
That is an interesting question. I'm not sure what the answer is. I
think when players play and create an avatar they do identify very
strongly with their avatars and they certainly often like who they are
more in the game than how they are in the real world. They prefer the
way they are in the games over their real world experiences. So I think
there is a very very strong identification with that. As a therapist my
challenge is getting the people who are helping players understand what
it is in the game that they like so much about themselves and help them
find ways to bring that forward into real world.
Is there any time
limit that says you've played too much?
You're not going to like my answer. There is some research which shows
a correlation between the amount of time and the signs and symptoms of
addiction. This is early research so I don't know if it is still true.
early research done in the 90s shows that people who spend more than 2h
a day online in entertainment - you know, not work, but online
socializing and entertainment - then they started showing signs and
symptoms of addiction. As a rule of thumb, people ask "What
should the time limit be?" I will always say "Don't spend more
than 2h if you want
to be sure you don't want to be addicted".
Yeah, but it can
be hard sometimes, really. Two hours is very little time, and it flies
Anyone could become addicted.
Cash: Remember that part of
the definition of addiction is that all addictions have some things in
common. It means, at least at the beginning, you get a high, because
you're enjoying it so much. Then the brain makes adjustments, because
it's getting too many of the neurochemicals and withdraws the receptors
to pick those neurochemicals out --that’s called tolerance.
spend too much online or in video games, your brain is making that
adjustment. And then, if you're not spending time online,
risk of going into withdrawal, when you're unhappy, discontented and
uncomfortable because you're not engaged in that activity.
stuff begins to happen, once you're body develops tolerance, then you
need more time or something new in order to achieve the pleasure
seeking. Then you develop tolerance to that new level. That's how it
works. Because you're hooked into that, if you start to feel out of
control, that's when you start engaging in being on the internet and
playing video games even though there are now, and will continue to be,
negative consequences. Those consequences could be alienation from your
friends and family, or physical health problems because you aren't
getting enough sleep, or problems with work or school and so forth.
Those are the elements that need to be there for us to call something
What do you think about the psychologist opinion that games are evil
and teaching players to be aggressive? Do you think that the games are
as bad as psychologists say or do they have any positive aspects to
themselves? How do you see that being a therapist in game addiction?
Cash: I think most games are
fine in moderation. The key is moderation. The whole subject of
aggression in games is still very controversial. I think it's not good
for children to be exposed to a lot of violence, whether it's
television violence, movie violence or video game violence. I don't
think it's good for the kids. I do think it begins to desensitize them.
The parents need to be selective about what video games they allow
their children to play. Once you're an adult even playing the violent
video games is fine in moderation. The lack of moderation is
problematic. I think there are lots of video games which can have very
positive benefits in peoples lives, but it must be viewed as moderate
entertainment and not viewed as "this is my new world and I’m
leave the real world behind."
What do you think
about the methods used in Chinese clinics?
Methods of beating, electric shock and so forth are horror stories;
those are terrible. I visited a clinic in Bei Jing and that is not one
of the clinics that have been reported as having any terrible things
happening. It was fascinating to go there, because it was a combination
of a military boot camp--a lot of very rigorous, vigorous physical
activity, wearing a uniform, learning to handle weapons--it was like
military training. It was this, but also Western-style psychotherapy.
They had sound trade play therapy, music therapy, group therapy,
individual talk therapy, and anger release therapy. Those are good
I came away from my tour of Bei Jing facility with
a basically positive outlook on it, although I would love to spend a
month or so just really observing what it was like. Still, my
impression was fairly positive. The clinic is run by doctor Tau who is
a very smart, capable and caring man. I think he's created a fairly
good Chinese-style program, very different from our own American style.
The other places may be absolutely awful. It's awful if anybody is
being beaten, electric shocked and all of that.
Do you think that
different nations can have a different method for addiction therapy?
think it's inevitable that different cultures are going to produce
different solutions. I can tell you that I have been contacted by
people in China who are very interested in trying to model what we are
doing over there. So they're interested in learning a gentler
approach. We'll see what comes about.
Are there any
statistics saying how many addicted players there are in US or China?
there any statistics at all?
Well, in the US the most recent research is suggesting that addicted
video game players range of about 8.5% overall of kids between the age
of 8 and 18; they meet the criteria for addiction.
Cash: For adults it's
actually very similar. It's interesting though. Nick Yee [author of the
Deadalus Project website -Ed.] spent his young career--he's pretty
young, about 30--researching inside MMOs. I haven't read his most
recent research, but I knew earlier it suggested that among MMO players
the rates of addiction were probably pretty much higher.
Could you tell us
any kind of special case of addicted player? What was the most unusual
Cash: The most unusual case?
I'll give you two. One is a 25 year old man whose wife came in with
him. He had been a star in high school and earned a scholarship into a
very exclusive university. He was an athlete, very socially popular and
loved to play games as well, but it wasn't a problem. His life was good
and he played games appropriately.
When he went off to the
university he got very anxious that he won't be good enough to succeed.
So, instead of working harder to be competitive, he escaped his anxiety
by playing MMOs and he was eventually kicked out. He married his high
school sweetheart and moved to the Seattle area where he got a job in
the computer industry. The game he had gotten so addicted to was style="font-style: italic;">Everquest.
He made a promise to his wife that he will never play style="font-style: italic;">Everquest
again. For one year he didn't play it.
But he played
he stopped playing MMOs. Things went all right. After a year he decided
it was ok, he could play again. He had made the promise to his wife
that he wouldn't and so he deceived her and started playing in secret.
He would go to bed with her and then when she was asleep he'd get up
and play the game. In the morning he would get up with her and pretend
he was getting to go to work, she would leave for work, but he stayed
and played the game. Of course he got fired from his job, but he didn't
tell her. He just kept up the charade of pretending that he was
working. He completely became addicted. He paid their bills with credit
cards and it was all a big lie. Eventually he became so depressed he
became suicidal. He confessed to everything to his wife who brought him
to me. There's an example.
Did it turn out
ok in the end?
Cash: Yes. It was great. He
was easy to work with, because he had lived his life to adulthood as a
very healthy young man. So, he knew what it felt like to be healthy. It
was easy, really. In the end, he knew he had to stay away from video
games entirely, like an alcoholic has to stay away from alcohol. He
just knew that about himself. Once he made that commitment he started
doing some twelve step work and as far as I know he's fine. They moved
away and I lost touch with them, but as far as I know they're fine.
case is a young man from this area who, again, had a pretty normal life
up until he went off to college. He played video games, but in
moderation. He was a good student, he ran cross country, and he had
friends and a social life when he went off to college.
very significant about him is that, although he had friends, he was
socially shy and he hated his father who was abusive. When he went to
college he met other gamers in the dorm and he just squeaked by passing
the first term. But, thereafter he would sign up for courses and then
he would withdraw by the withdrawal deadline. He lied to his parents
that he was still in college, taking all the college courses, creating
a fake transcript which he would show them to prove that he was doing
well. For 3 years he kept up that deceit and his parents paid for his
university. He didn't have anything to show for it. He eventually was
kicked out and was suicidally depressed.
He was much more
difficult to work with. He has been gaming at this level at that time
for about 5 years. He was very far behind in his social skills. He was
really scared to be out in the world--he had become agoraphobic, didn't
want to leave the safety of his room. So in the end he was unwilling to
end his gaming entirely. I couldn't make him do it. It was a very long,
slow process of working with him.
How long did it
I worked with him on a regular basis for 2 years. The best thing that
happened to him was that he did eventually have to work because he ran
out of money. Then he got a horrible job, so he wanted a better job and
he got that. Then he didn't like that job and he realized that he
needed his university degree. That motivated him to return to
university. They made him to write a whole essay about what happened to
him and why they should take a chance on him one more time. He wrote
that, they accepted him back, and he's a graduate. His life is slowly
improving, but he's now 26 and he doesn't date. He's way behind his
These were really unusual examples, I think. They were in a very
difficult position. Usually it isn't so difficult, right? Addiction is
more moderate, right?
The young who have come to us at the reSTART Program all have
similar stories. What I have found is that if somebody can come for
treatment when they are young enough and I can work with the parents
then treatment is easy. If they are older, in their twenties and mature
enough to realize what a fiasco they have created for themselves, and
they're ready to work and not in denial about their trouble, then
that's easy as well. What is difficult is when they are older teenagers
or young adults who do not yet admit they have a severe problem. Then
they're harder to reach. When somebody is still too strongly in denial,
they haven't experienced enough pain to be willing to get help.
WOMEN, MEN AND THE ADDICTION
Is there any
difference between women and men when they are addicted and any
difference in therapy?
Well, therapy always has to be adjusted to each individual. In general,
the women that I worked over the years have been far fewer in number
and their issues have often been centered on falling in love with
people in the game and developing a whole fantasy life around
relationships. It's different from what motivates a lot of men.
interesting point of view.
of the games that are very popular with women is style="font-style: italic;">Second Life.
be a place to live out fantasies and relationships.
There was a psychologist named John Carlton, who said that addiction is
a feature of personality. Are the persons who come to your clinic
easily addicted to other factors, for example smoking or something else
before coming to your clinic?
No. I do think once a person develops an addiction then they're more
vulnerable to another addiction. So I think they're often all called
addictions and it might be to drugs and the internet, smoking and the
internet, or whatever. Most of the people I have worked with over the
years haven't been addicted to anything except the internet.
Do you know if
after the therapy they became addicted to something else?
Not that I know of, except that I do a lot of work in that program in
our clinic called Internet/Computer Addiction Services inpatient--we
work with a lot of sex addicts and their partners. Those sex addicts
are, for the most part, very vulnerable once they give up their
addiction to pornography or sexual acting out. They have to be very
careful to not become addicted to something else.
Does the Ministry
of Health give any refunds for the therapy for addicted players?
Cash: Not at our inpatient
setting, but we work with the Diagnostic Statistic Manual [DSM-IV]
which has categories of psychological disorders and there's a category
called "Impulse Control Disorder". If somebody, like a video game
addict, comes to visit me at my office I can bill the insurance for
there any scientific name for the game addiction or was that "Impulse
Control Disorder" the name for the game addiction?
No, it is called “Impulse Control Disorder, not
specified.” So it is a general category that's not specific.
next version of the manual, which will be coming out in two more years,
there's going to be a large category for non-substance-use addictions.
We know gambling will be there, because there's a lot of research on
gambling. We're hoping that they will also include video
game addiction and perhaps sex addiction, but we don't know yet what
they will decide to include. It's all a matter of evidence, good
research, and it comes along slowly
change anything if they include it in?
Cash: I think it will be
huge, because then the insurance companies that pay for health
insurance will have to cover it in the same way as they cover chemical
dependency, drugs and alcohol. And it will be huge in terms of people
in my profession. So many people in my profession don't take this as a
serious problem. They don't like to think of this as an addiction and
don't know much about addiction in the first place. So if it gets into
DSM that will change the landscape a lot. So I hope it happens.
be great. Is there any test or quiz that you could give to our readers
that they could do and check if they have any problems with gaming.
Direct our readers to our website: href="http://www.netaddictionrecovery.com/" target="_blank">netaddictionrecovery.com
. There is a signs and symptoms checklist that they can go over and we
tell them how to score that. It's not a definitive, but it certainly
will give them an idea of whether they have a problem or not. style="font-weight: bold;">
play games? What kind?
No. But I have a son who is 19 and he enjoyed video games and so I
tried to play some video games with him, but I was so bad it was no
fun. Oh, there were some Mario games and... I don't remember the
name... Soccer, you know, FIFA.
you very much for explaining everything to us. It was a very
interesting talk. I think me and our readers will have a different view
on gaming or at least think in different light about it. That was
really educational. Thanks again.
Once again we would like to
thank the folks over at MMOZin for bringing us this interview, if you
would like to learn more about the clinic or need help with internet
addiction you can visit reSTART's website href="http://www.netaddictionrecovery.com/" target="_blank">here.