A few weeks back, I wrote a post about my own experience with a video gaming addiction. I received a lot of feedback from people sharing their own stories as well as asking for advice. Since I’m no therapist, I’ve decided to find some people who are and asked them for their recommendations. One of them, Dr. Brett Merrill, I interviewed a few weeks ago already.
This time, I’d like to introduce you to Dr. Hilarie Cash, who runs a video game addiction treatment center called reSTART. She agreed to be interviewed for this blog and share some advice for people struggling with an excessive, compulsive video gaming habit.
Karsten: Can you tell me a bit more about reSTART and the work you are doing there?
Hilarie: reSTART is a program that we started almost seven years ago because there was no place like it in the United States, and there was a need. When people come here, it is like coming to a retreat center. Everyone comes voluntarily. They’re adults, and we take no more than six people at a time in the first phase of the program.
While they’re with us, they have a break from technology in this first phase. It’s a large house on a beautiful five acres of land – so a rather rural setting – and our goals while they’re there are to just keep them away long enough from technology so their brains can come back to more normal functioning, to design a plan for themselves that will be serving as a blueprint going forward because, of course, we all have to use digital technology.
It’s very hard to have a modern life without it, but how are they going to use it without falling back into the addictive patterns that they’re trying to leave behind? This document called “The Life Balance Plan” is that path forward. We also are emphasizing health so we have quite a strong, rigorous fitness regimen, when they have time to sleep, good, healthy food and learning; teaching them quite a lot about health.
Karsten: How long do these six people stay with you?
Hilarie: The minimum stay is 45 days. We generally think of it as a 45 to 90 day stay, and then once they are ready to move on, if they choose, they can go into the second phase of our program called “The Open World Program.” This is transitional living where they’re living together in apartments one town over – in the city of Redmond – and they’re living with other guys who have all been through the program and are all trying to find their way in the world in a new way, without all of that tech overuse.
This program generally lasts quite a bit longer. They can stay any length of time but we encourage them to stay six months or longer. They’re finding jobs and maybe deciding to return to college, because the majority of them had failed out of college because of their gaming. We are shepherding them, still providing a lot of services, while they get used to being out in the world in this new way.
Karsten: What age are your average participants? What gender? What’s their background? I know they use technology a lot, but what else do they have usually in common?
Hilarie: They are adults between 18 and 30 usually, although we do have some older people coming. They are mostly young men. In the seven years we’ve been open, we’ve had six young women in that whole time, so it’s definitely men who are coming. They tend to be very bright, well educated, and they typically arrive feeling very depressed and very anxious. They also typically arrive with a diagnosis of Attention Deficit Disorder. A certain percentage of them have some traits that we used to call Asperger’s, so some of them have those traits. For the most part, they’re just lovely people, but they really have spent so much time in their lives online that they have, for the most part, not developed the skills and the comfort level that they need to be successful in the real world functioning as adults, so that’s what we’re trying to help them launch into adulthood through their participation in our program.
Karsten: Have they worked with a therapist, or are you their first point of contact? How do they find their way to you, and what do they usually try before coming?
Hilarie: I’m guessing maybe half of them have been to see therapists before, and sometimes it’s the therapist who makes a referral to us. Often times, therapists have seen that they are addicted and anxious and are trying to treat that. Many therapists – I think, incorrectly – make the assumption that if they can just address the depression and anxiety that the gaming problem will go away, and actually, what we see is the opposite. So often, when they stop the compulsive gaming, they take a break like this from technology, that very often the depression and anxiety go away. Some of them come without ever having been to see therapists and others have.
Karsten: I was writing an article about my own history of video gaming addiction, and after I published that, I received a lot of inquiries from people. Two of them asked me to pass on their situation and I’d like to hear your thoughts on it.
In the first case, the parents of a 14-year old boy wrote, very concerned about the time their kid spent playing; they were telling me about 7 to 10 hours a day and suffering in school. They’re not US.-based, so where they’re from there’s a lot of internet cafes, so they are afraid that if they remove access to the internet or to the game that their son will just end up playing at one of those internet cafes, putting him in an even worse environment. At this point they’re considering sending their son to a boarding school, or to maybe a school even for troubled children where he’s a bit out of this environment. What are your thoughts on this?
Hilarie: It’s very difficult to know what to do in a situation like this. If this family’s in Korea, then they are lucky because in Korea, they have 17 detox centers that will be appropriate for kids of his age, and that’s followed by six months of individual and family therapy.
That’s a pretty good model. I’m sure that works well for many teenagers like this who are having trouble. The fact that Korea recognizes that it’s a family issue and that the family relationships need to be repaired is important. I don’t know where this kid is but, in general, what I see is that there needs to be work done on the family relationship.
I recommend working toward repairing that, setting reasonable boundaries and involving their son in the conversation around how to perhaps slowly diminish his use. Involving him in the conversation so it doesn’t feel like just top-down control is important. In addition, they can help him find interesting replacement activities that they’re willing to support, and look at their own tech use and make sure that everyone in the family is abiding by a reasonable and limited amount of tech use and plays by the same rules. If they do that, there’s a chance of getting some buy-in from him.
That’s what’s needed when you’re dealing with a teenager or any child: it’s best if they feel invested in the rules around this use, and they feel they have their family’s support for being successful in the world and finding alternatives.
Karsten: How would you say they should approach this conversation? Because the experience is often that kids playing all the time react very angry if they get interrupted. Or they’re not really willing to have the conversation.
Hilarie: Your question is really tough because every family is different, and I don’t know this family at all. I don’t know that what I would say would be of all that much use. It might be that to just get his attention that they may need to block his access to the devices long enough to get his attention so that he will, angry as he is, agree to sit down and just talk with them about it. That might be an approach, but again, I’m real reluctant to answer your question because everyone’s different.
Karsten: Another case I received is a 22-year old in who said he’s been playing Runescape, a massive multiplayer online role-playing game for 10 years; not consistently, but he just goes on these binges and then quits for a while, and the moment he picks up the game he’s immediately immersed again for a few years. He gets drawn in again and again. What kind of advice would you give in that situation?
Hilarie: I am great believer in abstinence. If he’s willing to take some time away, I recommend talking to other people during that time, so he’s not just doing it on his own. At the very least, friends and family, but ideally a therapist who understood the problem.
While he’s taking a break – let’s just say he takes a break for a week from all gaming – he can try to think carefully about when he did play and do an analysis: When did he play? Where did he play? What were the things that really occurred that triggered his desire to play?
And then, try to develop a plan for changing all of that, because often, we’re such creatures of association and habit that if he can, for instance, set his computer up in some completely different location, if he can make sure that he is busy with other things during the time he would normally be wanting to log on and play Runescape, those would be examples of things that are enough of a change that he might be able to gain control over himself rather than falling just automatically into the addictive pattern that he falls into easily.
Having somebody who can help him analyze how to make changes so that he will be less triggered to fall into the old patterns and find alternative activities – again, it’s really key to have other things that you are interested in doing as replacements for that – that would be a place to start.
Karsten: You mentioned you’re a great believer in abstinence. That’s very interesting because I also heard some therapists say that they advised moderation.
It seems there are two different approaches to it: a complete abstinence program which, as a layman, I would associate with things like Anonymous Alcoholics and 12-step programs. Then there’s this moderation approach that seems to say it’s hard for people to quit if they think they have to quit forever and will never ever again be able do that. What’s your take on that? Do you think there is a higher chance of success if you just completely get out of these online role-playing games?
Hilarie: Yes, I do think that there’s a higher chance of success if you get out of them all together. When people come to reSTART, what we ask them to think about are their bottom lines, their middle lines, and their top lines.
Their bottom lines are the things that they recognize are their addictive behaviors, the things that when they do them are almost impossible for them to do them in moderation. They just fall right into the addictive pattern.
Many of our gamers say, “Any kind of video game is going to be a trigger for me. I’m putting all of those as a bottom line,” and when we have discussions with them about the future they might say, “Oh, I can’t bear the thought of never playing video games again.” Our response is usually “Maybe one day you will, but if you can commit to, let’s say, two years of no video games, it gives you two years to build a life that is outside of video games; two years for your brain to develop the neuro pathways that will support other activities.”
Research in addiction says that, typically, two years is about the time it takes to really heal from an addiction. So, we ask them to commit to at least two years of abstinence from whatever those things are they identify that they need to be abstinent from, and some of them are very clear. They say, “Oh my gosh! I really better never do video games again because it’s just a disaster for me.” Others say, “Okay, I’ll commit for a year.” Others say, “I’ll commit for two years,” and then our advice to them is, when you decide that you want to reopen this question, then we’ll say to them, “Don’t do it on your own.” If you reach that point where you really do want to reopen the question of, “Should I return to gaming or not?”, do it in conjunction with people who know you and trust you and understand what it is you’re doing in your effort to stay sane and healthy. If they can agree to that, then we think their chances of long-term success in having a healthy relationship to technology is much increased.
Karsten: Would you say there’s a difference in terms of the type of games people talk about playing?
Hilarie: I think that everybody has their favorite games that they have had really addictive relationships with. The pattern I see is that it’s almost always the multiplayer games, so those are going to be always the most dangerous games. So, one of things, for instance, that they will do when they create a plan for themselves is they will say, “All right, for two years I’m not going to play anything, and then in two years time, if I’m feeling like I want to return to gaming, I’m just going to experiment with something that’s just a single player game and I’m just not going to do the multiplayer online stuff,” and we say, “Okay, good luck.” I just want to comment that the reason moderation can be so difficult is because the brain becomes permanently sensitized to the cues that it has developed a high sensitivity to.
There’s a saying in all addiction work that once a cucumber becomes a pickle it can never return to being a cucumber. So, for some people, that is going to be true. For other people, it might not be true; maybe they can return to being cucumbers, but that will be for them to figure out and to try if they want to.
Karsten: How do you advise people to make the choice between seeking out an on-site program like reSTART, where they are completely immersed for a period of time versus having contact with a therapist once a week?
Hilarie: reSTART grew out of my own experience as a therapist. I first started working with folks who are internet-addicted. My first client who was addicted to a multiplayer online game was 22 years ago. I had lots and lots and lots of experience of people seeking help for their internet addictions – be it gaming or porn or other things – and I really saw that for many of them the once a week or even twice a week meeting with me was simply not sufficient to break the addictive habits. I was always frustrated because if someone is addicted to porn, they can go to a treatment facility that’s really set up for sex addicts and get the help they need there to really break the addiction.
There was nothing like that set up for gamers and other internet addicts. That’s why we started it. If you have somebody who’s highly motivated and they’re really willing to work with a therapist, it can be successful. But, if they’re reluctant and if there isn’t a lot of support around for them, it often is not successful. If it’s going to be outpatient, it requires a high level of motivation.
Karsten: Do you have data on relapse rates of your former clients?
Hilarie: We don’t have any formal statistics, and we are actually gathering that now. We have a PhD student who has asked that question, and that is going to be her dissertation. We’ve sent out the questionnaires, and we’re waiting for those to be returned so that we can begin to answer that question. 50% of our participants go on to Phase Two. It seems to me that about 75% of those who go into Phase Two are doing quite well; even if they stumble and struggle, that ultimately they do very well. About maybe 25% – again, it’s just a guess – really ultimately drop away and may not be doing nearly as well. But, check back with me in a year, and hopefully I’ll have a good concrete answer for you.
Karsten: The extent of the program seems to hint that there’s probably a substantial amount of costs involved for people seeking out the program. What does it cost to go through the reSTART program?
Hilarie: In the first phase, it costs $25,000 for 45 days. In the second phase of the program, it is much less costly because it’s less intensive, and the first month is $7,500, and then it drops by $1,000 a month until it stabilizes at $2,500.
Karsten: What do you recommend to people who would not be able to afford that but feel they have a serious problem?
Hilarie: I would recommend that they seek out a counselor who takes internet addiction seriously and is willing – even if the therapist doesn’t already know about much about it – to learn, and will do some research or consultation or whatever they need to do to get up to speed. Often, finding a therapist who has a specialty in behavioral addictions, like gambling or sex addiction, is going to be a safer bet than a therapist who doesn’t do behavioral addiction.
I really would recommend people find such a therapist if they possibly can, and secondly, that they attend 12-step meetings of any sort so that they’re not trying to do this alone. Trying to conquer a problem like this in isolation is just incredibly difficult, so seeking out a group – even if it’s an Alcoholics Anonymous group – helps. You can join them and let them know that the addiction is not the same. You can find an Alcoholics Anonymous group almost anywhere, and it is a recovery community. I would recommend that they attend 12-step meetings for community and that they involve the family – especially anyone they’re living with – because the dynamics of what goes on in the family or the couple-hood is going to make a huge difference to long term success. The whole system has to grow to be healthy to support recovery.
Karsten: Do you have any last piece of advice for people reading this right now?
Hilarie: I guess the only other thing I’d want to say is that it’s so important to understand that online socializing is not an adequate substitute for face-to-face social contact. The research is quite clear. Time people spend online tends to be correlated with increased anxiety and depression. We are social animals; we need social contact. Many people, I think, are drawn online because they want social contact and they’re finding communities online.
But it is in fact the face-to-face relationships that stimulate something called limbic resonance, which is a neurochemical release in the brains of people who feel safe and cared for in one another’s presence, and that’s what keeps us regulated happily, physically and emotionally. Even though I know people in games, for instance, have friends there and count those friends as dear and important to them. I just would like gamers and anyone else who is spending inordinate amounts of time online to recognize that they really need to work on their face-to-face relationships in order to ultimately be happy and healthy.