Understanding and Dealing with Gaming Problems: A Q&A with a Therapist

Shavaun Scott has an incredibly unique perspective on online games. She is a licensed Marriage and Family Therapist, has been working in addiction treatment since the late 80s, and has been a therapist for individuals, couples, and families since 1991. Moreover, as an MMO gamer herself, and a mother with two boys who sometimes spend too much time playing MMOs, the issue of “online gaming addiction” is something she takes very seriously and has thought a great deal about.

In the media, discussion of online games oftentimes degrades into sensationalist sound bytes, and it is incredibly difficult to find sensible strategies to many common problems. For example, what is the best way for a concerned parent or friend to approach someone who has a gaming problem? What are things they should and shouldn’t do in these situations? These were also questions that I wasn’t trained to address (as an experimental psychologist).

So when Shavaun agreed to be interviewed for an article on understanding and how to deal with the common problems, I was very excited. I also want to take a moment here to say how much I appreciate her taking the time to provide such thoughtful and insightful responses to some very difficult questions.

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The word "addiction" has lost some of its clinical meaning in popular culture. Many people claim they're addicted to coffee or golf. What do you think are common misconceptions that people usually have about the causes and nature of clinical addiction or behavioral dependencies in general? Or put another way - If there's one thing that people need to know about clinical addiction, what do you think it should be?

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What about relationships, and in particular, the complications that arise from comparing the value of face-to-face and online relationships?

Why do some people develop compulsive behavioral problems?

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You mentioned that children are special cases because their ability to self-monitor and self-regulate aren't fully-developed. Can you elaborate more on that?

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What are practical measures that parents should take to help their children regulate their game-play?

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You mentioned elsewhere that you’ve been seeing more and more people who come in because their partner has a gaming problem. Tell me what those scenarios usually look like.

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I've always felt that the people who realize they have problems and are willing to see therapists are the easy cases. I think the hard cases are people who deny having a problem, and become violent/antagonistic when someone implies they have a problem. In the case of a partner with a gaming problem, how should someone approach the issue or convince them they have a problem?

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And finally, I also asked Shavaun for some do’s and dont's for people who are concerned about someone they know who might have a problem. This set of points also helps summarize many of the important things Shavaun brought up throughout the interview.

I'd like to thank Shavaun again for taking the time to address these questions. You can contact Shavaun at "therapist @ dreamtreader dot com".

See Also (more recent articles listed first):

- The Trouble with "Addiction"
- A New Disorder is Born
- Problematic Usage
- The Seduction of Achievement
- Addiction
- Understanding MMORPG Addiction

The Trouble with "Addiction"

I think the wikipedia entry on “game addiction” is very telling. While you would think the entry might at least cover several genres of video games, the only genre it names specifically is MMOs. More interesting is that for over a year the neutrality and factual accuracy of the entry have been debated on the discussion page, but very little has changed. Comments such as the following are typical of the background discussion.

I've added {{disputed}} and {{POV}} tags to the article. Honestly, I don't think it can be salvaged at all, although that doesn't mean we should VfD it, as there ought to be an article on this subject. However, this article is a great example of exactly how not to write a good Wiki article. Junjk 19:37, 31 July 2005 (UTC)

What the wikipedia entry shows is that it’s not easy to talk about “online gaming addiction”. This is partly because “addiction” is a very loaded term. And it bears emphasizing that “addiction” is a very complicated concept. Some things, like coffee, cause physical addiction, and most people who drink coffee are technically addicted to coffee, but few people think of that addiction as a bad thing. On the other hand, marijuana is not physically addictive, but people can become psychologically addicted to it, and that can become a bad thing. Some people say they are addicted to knitting or the TV show “Lost”, but most of them are neither physically or psychologically addicted. They just use that word to imply how much fun they have with their hobby. But just because some people can become psychologically addicted to shopping or golf (or other idiosyncratic and bizarre activities) doesn’t mean that these activities are addictive for everyone. Finally, falling in love is also a kind of addiction that can both enable some people while completely disabling others. In other words, the same addiction can be good for some people while being bad for others. And just as an illustration of how casually we employ the metaphors of addiction in our news media, a recent news report of a scientific study found that “the simple act of talking triggers a flood of brain chemicals which give women a rush similar to that felt by heroin addicts when they get a high”. In short, women are addicted to talking.

To say this issue is complicated would be an understatement. But I want to say the complications are conceptual rather than factual. Here’s what I mean. If I said “the President of the United States has one leg”, that statement would actually be factually accurate. It also turns out the president has half a brain. While these statements are semantically misleading, they are both logically true. And I think the same thing is going on with the discussion about “online gaming addiction”. What’s clear is that there is a real problem. There’s a great deal of evidence that some MMO players spend so much time playing MMOs that other parts of their lives (work, academics, relationships) are severely impacted, and that they have trouble accepting they have a problem and controlling their play patterns. On the other hand, the simplistic framings and perspectives that dominate the media on this issue are somewhat misleading. And much of this is due to how loaded the term “addiction” is how it shapes discourse around online games. When shallow comparisons between online games and cocaine are made, what’s left out is the other leg. And I would argue that if we really want to understand the nature of the problem (and actually help these people), we have to understand the bigger picture.

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Cherry-Picking Addictions

As big as the stereotypical jock vs. nerd divide is in high schools, there are a great deal of similarities between football and MMOs. They are both social activities that take place in a cordoned-off portion of the real world. In these virtual worlds, different rules come into play. Players take on fantasy roles that only have functional meaning in the fantasy world. They are awarded points for arbitrarily-defined tasks. Cooperation and competition play large roles for players in both worlds. And it isn’t uncommon for players in both worlds to develop significant relationships with others they have played with.

On the other hand, there is a tremendous difference in how people interpret tragedies that occur in these two worlds. High school and college students on football teams regularly die during practice (1, 2, 3), but their deaths are dealt with by the media with a very holistic perspective. The media questions whether the coach set an unreasonably exhausting regimen. The media questions whether the parents saw warning signs. They ask whether the school reviewed the coach’s history thoroughly when the hiring was made. They wonder why the school mandates year-round practice that necessitates training in the hot summers. They ask whether the team physicians condoned the exhausting practices despite the individual’s particular health idiosyncrasies. And in no time during all this does anyone suggest that football is addictive and caused the deaths. This is because that statement would be naïve and simplistic.

When people die during or after playing an MMO however, it is typically “caused by an online gaming addiction”. The wikipedia entry on “game addiction” lists several of these “notable cases”. Even in cases where the person suffered from depression and other mood disorders, an “addiction” to the game itself is primarily blamed for the deaths. As another example, Kimberley Young’s discussion of Internet Addiction Disorder implies that marital affairs that occur online are primarily the fault of the Internet, rather than having to do with personal choices. Why is it that explanations are complicated and holistic when it comes to football, and so simplistic when we talk about online games? Part of the reason is that football is too mainstream and too low-tech to be a tool for the media to instill paranoia with. No one is afraid of a leather ball.

We pick and choose what we label “addictions” in other ways too. For example, pedophilia is a kind of “child addiction”, but no one blames children for causing the addiction. We don’t argue that children are accessible, controllable, and cause excitement and thus cause “child addiction” (analogous to Kimberley Young’s ACE model of Internet addiction). We don’t argue that molesting a child causes dopamine increases and is physiologically reinforcing over time. We don’t blame the child fashion industry for deliberately designing cute clothing that attracts pedophiles. We also don’t blame shopping malls for kleptomania. I would argue that the level of social acceptance for technologies, objects, and people influences how likely we blame them in analogous scenarios, and how likely we take on holistic as opposed to narrow perspectives in trying to explain the problem.

To argue that the application of “clinical addiction” on to different behaviors is somehow an objective scientific process is to ignore the fact that all social institutions are embedded in cultural and financial frameworks that shape their beliefs and actions. Many embarrassing “mental disorders” have been included in the DSM in the past - being gay used to be a pathological behavior. Whether a novel behavior tied to a novel technology qualifies as an “addiction” is anything but a simple matter.

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Are MMOs an ingested substance?

When people use the term “online gaming addiction”, they are encouraging others to think of online games as a kind of physical substance. This is a rhetorical move that asks the audience to ignore everything about MMOs except that they are like alcohol or cocaine. The problem is that online games aren’t simply liquids or powders that are ingested. Online games are also not simple behaviors like gambling.

Online games are social worlds with their own geography, culture, dialect, and social rules. They are places where protests and vigils are held. They are places where slang and etiquette rules emerge. They are places where people meet and then get married face-to-face. And to the extent that they are social places, asking whether someone can be addicted to an MMO is like asking whether someone can be addicted to the United States. To see how analogies with cocaine and alcohol fail with social places, we can paraphrase a survey item for diagnosing Internet Addiction Disorder: “Would you become irritated and frustrated if you were unable to live in the US?”

Up till now, the label “addiction” has never been applied to a social place. It has been applied to substances and simple behaviors such as gambling. When the media and others use the term “online gaming addiction”, they are asking us to ignore all the ways in which an online game is different from an ingested substance. It is this confusion that leads to the generation of simplistic and double-loaded questions that further muddles the issue:

- Are online games detrimental, addiction-feeding?
- What do you believe is the leading cause for internet addiction?
- What percentage of MMO players is addicted?

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Rational vs. Pathological

Another assumption in the “addiction” rhetoric is that the real world is wholesome and fulfilling while the virtual world is impoverished and limited. There are several problems with this assumption. First of all, there are many sociological texts that describe how the real world can be limiting for many people. For example, consider “Nickel and Dimed” by Barbara Ehrenreich or “Teenage Wasteland” by Donna Gaines. Gaines’ book is particularly insightful in pointing out why suicide can become a rational and attractive decision for suburban teenagers who feel trapped in social structures of unsatisfying options they can’t escape. While it would be nice to think that the real world is perfect for everyone, this is simply not the case. There are many people who, for a variety of reasons and circumstances beyond their control, have very limited options in life. Some of these people may find leadership and affiliation opportunities in virtual worlds that they don’t have in the real world. Please note that I’m not arguing that this makes online worlds “good” or “wholesome” or that this means people in these cases are living in a healthy and fulfilling manner, but I am trying to point out how complicated these comparisons are. Specifically, the question we need to ask ourselves is this. Until the world is a perfect place for everyone, is it actually pathological for some people to prefer being in a place where they have social status and respect?

Ted Castronova has also made the same point in his book “Synthetic Worlds”:

The broader social issues become clearer. When the virtual world becomes the only decent place to live for some people, is it their fault for making a rational choice or is it our collective fault for perpetuating social structures that produce unsatisfying living conditions? Is the online game simply an “addiction” for these people?

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Getting Past “Either-Or” (Part One)

Another complication with MMOs is that they can be therapeutic and destructive at the same time. While the media likes to describe the issue is terms of polarized pro-game and anti-game opinions, it’s not clear why online games can’t be both enabling and disabling at the same time. For example, some people have access to social opportunities in virtual worlds that they do not have in the real world. And no, I don’t mean resurrecting the dead. Teenagers who are sufficiently mature can become guild leaders and take on a leadership and management role in a group of a dozen or more adults. It bears emphasizing that this kind of social opportunity does not exist in the real world for teenagers because of how our society is structured. In the real world, teenagers aren’t allowed to lead a large group of adults, set their play schedules, draft rules and guidelines, and resolve their personality conflicts. It’s not hard to see why these opportunities can be seductive for all the right and wrong reasons.

A more complicated example comes from a recent article from the American Journal of Psychiatry (Allison, Wahlde, Shockley, & Gabbard, 2006). In this case study, an 18-year old patient (referred to as Mr. A) with online gaming problems received diagnoses and recommended treatment from a panel of four clinical practitioners. The case presentation was clear in describing the contextual factors of Mr. A’s life history that may have played a role in the development of the problem. For example, one therapist noted that:

The authors also struggled with whether “online gaming addiction” was a meaningful diagnostic category.

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Getting Past "Either-Or" (Part Two)

The recommended treatment plan emphasized how complicated the case was in that the online game provided both therapeutic and destructive roles in Mr. A’s case. The authors presented an incredibly nuanced view of how the online game can both help and hurt the situation.

As with other activities in life, it starts to become clear that moderation is key. Online games can be therapeutic and enabling when engaged with in moderation, but can become disabling when someone plays too much. While seemingly obvious once laid out, this sensibility is oftentimes missing when the issue is presented by the media or anti-game proponents. A complicated “both-and” issue becomes mangled into a far more simplistic “either-or” / “good vs. evil” issue.

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Technologies as Reflections of the Human Condition

I think technologies such as the Internet and online games are also far more than just tools that people use and “become addicted to”. To some degree, they also reflect the human condition. Sherry Turkle, who is well-known as the author of “Second Self” and “Life on the Screen”, recently gave a talk at Stanford about her more recent work with how people perceive and relate to robots. An interesting finding was that children and the elderly readily express feelings of love and affection for robots, especially if the robot needs to be taken care of (google “Paro” or “My Real Baby”). In the Q&A section, someone asked about whether under-privileged children reacted to robots in significantly different ways than normal/over-privileged children (i.e., because of their different levels of exposure to technology in general). Turkle responded that there were no significant differences, except that when asked whether they would want to take Kismet home with them, under-privileged children often mentioned they wanted to take Kismet home because Kismet wouldn’t hit them or hurt them.

As Turkle mentioned elsewhere in her talk, technologies can be reflections of the human condition. In this case, the technology had evoked a response that revealed something very important (and troubling) about these children’s lives. Now, we could very well argue that these children have developed a psychological disorder, an aberrant expression of affection and irrational attitudes towards inanimate objects. And it wouldn’t be hard to do that, if you heard the kinds of things they say and do for the robot. But I think that would be missing the more important point, that talking about “irrational attitudes” would be a way of *not* talking about and dealing with prevalent child abuse.

This is also what’s partly frustrating with the emphasis on “online gaming addiction”. To ask whether teenagers are getting “addicted” to online games is a way of not asking why our schools are failing to engage our children. To ask why some people get “addicted” to their fantasy personas is a way of not asking how we expect people to derive life satisfaction from working at Wal-Mart. MMOs are seductive because they empower some people in ways that the real world does not. The people who we let fall through the holes of our social fabric are caught by an alternate reality where they feel a sense of satisfaction and purpose.

Creating labels such as “online gaming addiction” gives us the illusion that we’ve identified a new problem in our society instead of talking about the real and chronic problems in the world we live in. Instead of talking about why our education system is failing us, or why a tedious 9-5 existence is inevitable for so many, we have created a way of not talking about those problems. People who find empowerment in an unsatisfying world are labeled as “addicts”. We brush aside the larger social problems by labeling their victims as deviants. And along with that, all the nuances, complexities, and multiple factors in behavioral and psychological problems are ignored in favor of a simplistic single factor model.

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Ending Thoughts

The word “addiction” is loaded. It would be naïve to say otherwise. While there are more nuanced ways to use that word, such as differentiating between “being addicted to X” versus “X being addictive” for example, this is seldom the case when online games are dealt with. And people who use that term are deliberately setting themselves up for resistance. If they really wanted to help people understand how complicated the problem is, if they really wanted to reach out to the people who are having these problems and actually help them, there are other more neutral ways of saying the same thing. People will resist the label “online gaming addiction”, but no one would argue that some players spend too much time in an MMO, that sometimes players develop dependencies to an MMO and the dependency can cause a severe impact on their work and relationships. And most importantly, that these people need help.

It would also help to acknowledge that oftentimes, other factors such as depression, low self-esteem, mood disorders, high stress, or traumatic events such as unemployment or marital crises can make a person more susceptible to developing a dependency on a variety of potentially destructive behaviors, including playing online games. It would help to mention that behavioral dependencies in general share many common features and predisposing factors, and that creating loaded terms for specific technologies can make it harder for people to understand and help resolve the problem when the rhetoric focuses so singularly on the technology. And finally, it would help to mention that behavioral problems seldom have simple and single causes, but rather are typically produced from and sustained by a variety of inter-related factors. It doesn’t really help anyone when the entire issue often boils down to simplistic “yes/no”, “good/evil” stances in media reports.

I would argue that with our current social paranoia, using the term “online gaming addiction” is a rhetorical strategy for implying a lot of conceptually misleading things. It is a strategy that asks the audience to take on a simplistic view of what online games are, a strategy that plays to the fear-mongering of the news media and parental concern with video games and the internet. And ultimately, it is a strategy that in fact makes it harder for everyone involved to understand and help people with very real problems (particularly parents and therapists who know very little about online games). The label “online gaming addiction” encourages people to associate the underlying problem with the technology rather than (and in addition to) the person or their circumstances. It encourages people to ignore the therapeutic and enabling potentials of MMOs. It asks people to assume that MMO experiences are always limiting and unsatisfying. But the fact of the matter is that it’s much more complicated than that. And as I mentioned at the beginning of the article, there is a huge difference between stating what is logically true and what is conceptually meaningful. And I would argue that you can’t understand and help people with two legs if you only think they have one.

See Also (more recent articles listed first):

- A Q&A with a Theapist
- A New Disorder is Born
- Problematic Usage
- The Seduction of Achievement
- Addiction
- Understanding MMORPG Addiction

Addiction

About 40% of users would consider themselves addicted to the game. This percentage is quite striking given the social desirability bias built into the question. There were no gender differences, and age differences were minimal - about 2 years between “definitely” and “definitely not”. In other words, male and female users of all ages are about equally likely to consider themselves addicted to the MMORPG they are playing.

The average hours played per week in each of the five responses offer perhaps a rough guideline as to how much game play is too much game play. As a comparison, typical Americans watch about 27 hours of TV per week.

There were interesting correlations between this self-reporting of addiction and motivations. In particular, self-reported addiction was positively correlated with scores on Achievement (r = .25) and Escapism (r = .25). This finding dovetails with an earlier discussion of addiction. It appears that both internal (skinner box model) and external factors (compensation model) contribute to addictive behavior.

Note (12/02/2006): This data is complicated and can be misleading for several reasons. First of all, there is no accepted definition of "online gaming addiction" to begin with, so it's not clear what players meant by that (or why we would trust people to diagnose themselves even if that were the case). Secondly, it's not clear they didn't just take the statement to mean "the game is very fun" as the word is used commonly in the game industry. And finally, we have no comparison data with other hobbies - i.e., If we asked golfers that question, how many would have said "yes"? In other words, could it be that 40% of users of all hobbies would say they are "addicted" to their hobby (whether that is golf, knitting, or watching the TV show "Lost").

See Also (listed in chronological order):

- Understanding MMORPG Addiction
- The Seduction of Achievement
- Problematic Usage
- A New Disorder is Born