Video/Computer Gaming Addiction
Behavioral Treatment Protocol
Kenneth Woog, Psy.D.
Computer Addiction Treatment Program
Original article published (2016) in the journal Addicta
Updated August 13, 2017
Background
Video games have become extremely popular worldwide. It is estimated that the global video game industry in now over $100 billion in yearly sales and will continue to grow at nearly a 9% rate annually (1). Including mobile games played on tablet computers and smartphones, there are approximately 2 billion gamers worldwide.
Although there were published reports of computer addiction as early as 1980 (2), it was not until Nick Yee’s on-line survey of players of Massive- Multiplayer On-line Role Playing Games (MMORPG) in 2003 (3) did evidence of large scale on-line gaming addiction appear. In his on-line survey, 50% (n=3166) of the players self-report being “addicted” to their game (Everquest). Further, 70% reported playing continuously for 10 hours or more and 18% report that playing on-line caused them financial, health, relational or work problems. Between 4.8% and 30% of those surveyed stated they have “attempted to quit the game but were unsuccessful”, depending on age and gender. Players reported playing an average of 23 hours per week.
However, other than the on-line survey conducted by Kimberly Young in 1999 (4) and the study this researcher conducted in 2003/2004 (5), little information is known regarding mental health professional’s exposure to problematic computer use and treatment in the United States. In this researcher’s post card survey of mental health professionals in the United States (n=229), two thirds (67%) of clinicians reported seeing a client with issues related to problematic computer use within the past 12 months. The average number of patients seen by clinicians related to problematic computer use was 3 adults per year. In the age group 11-17 years of age, clinicians reported seeing less than one client (0.7 avg.) per year. Gaming was the number one endorsed problematic use for this age group.
Clinicians in the United States are seeing patients reporting problems related to problematic computer use. The on-line directory for Psychology Today (psychologytoday.com) now includes “Internet Addiction” and "Video Game Addiction" as “issues” of treatment that clinicians can endorse on their on-line profile. A search of mental health professionals in or nearby zip code 92630 (same as this clinician’s office) returns 78 therapists. Of these, 10 (including this researcher) endorsed the “Internet Addiction” issue in their profile.
Despite widespread public press reporting of the problem over the past decade there still is no approved mental health classification or criteria for diagnosing any form of computer or internet dependency in the United States. Debate continues as to whether this problematic use is a distinct disorder or simply a symptom of other problems (6). Despite this debate, many assessment instruments have been proposed (7) and in 2014, the American Psychiatric Association published the Diagnostic and Statistical Manual DSM-5 and included preliminary diagnostic criteria for “Internet Gaming Disorder” in the section recommending further study (8). Although “Internet’ is a part of the title of the proposed disorder, it is the opinion of this researcher that the term should be renamed to “Gaming Disorder” to reflect that using the internet for gaming is not a requirement, just as it wouldn’t be in pathological gambling. While not common, this researcher has treated individuals with problematic gaming that were not playing online. It would further reduce the confusion over other potential forms of problematic technology or internet use which may have very different presentations and treatment methods.
Besides not having an agreed-upon distinct mental health diagnosis, for those treating “Gaming Disorder”, there is very little research support guiding treatment. Effective cognitive-behavioral methods for treating gaming addiction have been reported (9) however the quality and quantity of this research has been limited. Clearly more research is warranted. This paper proposes a direction toward future research in treating problematic and addicting gaming using behavioral methods.
Etiology of Gaming Disorder
Although the mechanisms causing problematic video game play and addiction are not fully known, there are some indications. For those that have been seen by this researcher over the past 15 years, almost all play or would play more than 30 hours per week if allowed. Most have had a long history of extensive game playing. It is most often the case that these players were able to manage a lifestyle of school and gaming for years. To bring them into treatment, most have had serious life consequences as a result and many also suffer from anxiety and/or depression. The types of games played vary, however the majority are addicted to on-line role-playing games. Ten years ago, few sought treatment for game play with console systems like Sony® PlayStation® or Microsoft® Xbox®. Today this is common. It is this researcher’s view that both the amount of weekly play and number of months playing are factors in the progression of the disorder. Further, the nature of the game itself plays a role. Some games seem to be more addicting than others.
This researcher has identified several patterns that are common across the majority of patients. Parents of these clients reported becoming trapped in cycles of providing and withholding the computer or video game console in an attempt to change the child’s behavior. These cycles progress in phases from attempts to moderate daily use to removal of the computer or video game console for a period of time and for some a no-win power struggle between the child and parent. These attempts all failed to effectively moderate use and allowed gaming excesses to continue over an extended period of time, often years.
The most recent theories of addiction (10) implicate the effects of multiple neurotransmitters in various portions of the brain, however most notably dopamine within the reward (pleasure sensing) regions of the brain. It has been suggested that gaming addiction is a form of behavioral addiction, similar to gambling addiction, and that the same neuropathways are involved as in other forms of addiction, including substances (11). If this is true, then game play can be conceptualized as providing positive reinforcement to the reward center and negative reinforcement to other regions of the brain related to withdrawal/negative affect and craving/preoccupation. This suggests that gaming addicts would experience withdrawal, craving and preoccupation symptoms when unable to play. This is consistent with this researcher’s clinical experience.
The mechanism of reward center activation presumably serves to direct an individual to a pleasurable and satisfying life direction. However, when powerful successes (reward center activation) occur within the context of computer gaming, this will not necessarily translate into real life success. When driven to repeat the behavior more and more at the expense of other important responsibilities, negative life outcomes are likely.
It is theorized by this researcher that gaming addiction occurs when, as a result of game play, sufficient reinforcement is applied to the reward center and other brain regions. A net combination of individual differences (age, gender, genetics, co-occurring mental illness and life experiences) and competing/complementary reward systems within the individual’s environment determine what amount of reinforcement is “sufficient” and ultimately who becomes addicted and who does not.
For those that play excessively, this researcher further theorizes, similar to substance addictions, dopamine receptor changes in the reward regions reduce their availability resulting in tolerance effects and the elevating of the pleasure sensing threshold. The elevation would likely result in the reduction of pleasure associated with other previously enjoyed activities and the pleasure associated with the anticipation of these activities. This is consistent with the majority of clients this researcher sees in clinical practice. They need to play for hours to maintain a stable mood and they have lost interest in and are not motivated to engage in other activities.
Since the theory proposed in this document suggests that behavioral addiction involves changes in the brain’s reward center and other regions, stopping the addictive behavior alone will not undo these changes. The conclusion here is that abstinence alone will likely not cure gaming addiction.
New Learning in the Reward Pathways
The opiate blocker Naltrexone has shown effectiveness in treating gambling addiction (12) and has been suggested as a possible treatment for gaming addiction (11) as well. Presumably this drug would limit activation in the reward pathways during play. While this treatment approach seems to directly target the brain regions implicated in addiction, this researcher has concerns over the use of this medication on children, adolescents and young adults for this purpose. There is no way for the midbrain to distinguish between game rewards and real-life rewards. This may have serious clinical consequences when attempting to guide a young person toward a successful real-life direction.
Alternatively, a strategy is proposed to target the same brain regions behaviorally without limiting reward center activation for other activities. Behavioral treatment methods may be preferred over other strategies for individuals brought to treatment by their parents and yet remain in denial regarding their addiction. It has been this researcher’s experience that these individuals do not want to be in treatment and are particularly resistant to establishing a therapeutic clinical relationship.
Behavioral Treatment Strategy
Gaming addiction appears to be caused by excessive game play with “sufficient” reinforcement to the reward center and other brain regions. It is hypothesized that to break the addiction, these same regions must be the target of change to mediate the effects of the previous reinforcement. It is proposed that by reducing the amount of allowed game play, natural consequences of this reduction result in significantly reduced rewards of play. While continuing to play with a continuously lowering perception of reward and pleasure, it is hypothesized that changes to the brain’s reward center ultimately result in a reduction in the individual’s motivation to play. Other non-gaming, reinforcing activities would substitute for the time taken from gaming and coping skills would be enhanced through counseling. Rather than a reduction in gaming time seen as a treatment goal, it would be conceptualized as a treatment intervention. The three treatment steps suggested are:
1. Reduce the amount of available game time gradually. The net rewards from the game play will reduce naturally.
2. Reduce/limit activities that offer game-complementary reinforcement.
3. Introduce competing, non-gaming activities that provide reinforcement and are used to fill time made available from the decline in allowed gaming time.
Reduce play time and time on-line
While the moment to moment game play may be exciting and have reinforcing value, other reinforcement comes from the actual end rewards of play. This includes gaming level, rank, loot, armor, power and prestige. While the clinician cannot alter the game’s reward system (rewarding aspects of play) or the environment (i.e. other players, new exciting updates) of the game, the amount of play time can be controlled.
By reducing the amount of game play, the quantity of moment to moment reinforcement is obviously reduced. But more importantly, even a modest reduction in the amount of game play can significantly lower the game’s net rewards. This occurs in three ways. First, many games reward the amount of time played with the team (participation points) as a way to determine who gets the most “loot” or ranking. Second, since play is competitive, a player is likely to see his or his team’s rank decline as play time is limited. He may even be forced to change to a lower ranking team that can accommodate a more limited play schedule. Lastly, reductions in time online will likely limit on-line socializing or engaging in “pseudo-play” (activities related to gaming) thus lowering the reinforcement of these activities as well. Examples of pseudo-play include watching others play through streaming or “eSports”, researching game tricks/cheats, visiting web sites and forums discussing the game play.
Continued play with gradually reducing rewards of play will, presumably lower the gamer’s expectation of rewards of such play and lower the individual’s motivation for play. Motivational interviewing, supportive counseling and cognitive behavioral techniques can be used to enhance alternate coping methods. It is believed that if this reduction is done gradually, the individual can acclimate to the change without serious abreactions. The rate of change and the starting and ending point (hours/play per day, week, etc.) should be considered carefully for each individual. Obviously ending play usage amounts should be realistic for the lifestyle chosen by the client and not leave the client at continued risk of addiction. The limits should be imposed for as long as possible to ensure long term treatment benefits.
Challenges
This treatment strategy can be particularly challenging. Simply recommending a client monitor and limit their own game play time will likely be ineffective for those truly addicted or for children and defiant adolescents. For children and adolescents clients, parents must be willing and able to enforce time limits on play and to gradually reduce the allowed amount. For adult clients, this is more complicated. Logically, the overwhelming majority of adult patients presenting for treatment in this researcher’s office, continue to be supported financially by their parents or other family members. This suggests an opportunity for parents to assert their authority and establish and enforce play limits agreed upon in treatment. If adult clients that live independently are motivated for treatment, they may authorize a third party to set and maintain the limits for them.
Attempts to limit play time in the past have likely failed so parents will likely require counseling and technical support. Unfortunately, operating system and gaming console parental controls are often not effective in stopping an adolescent or adult gaming addict as they are too easily bypassed. Since the young person is often more technically knowledgeable than their parents, parents are at a disadvantage when attempting to enforce limits. Currently the best option for limiting on-line game play is to use a network router with parental controls and making sure it is physically secure
In addition, all substitute devices such as tablet computers and smartphones must be limited or removed to enforce the game play and on-line limits. While limits on gaming time in the home does not limit use outside the home (not as big an issue in the United States), it will likely still result in reductions in play time.
As a result of the challenges posed by this treatment strategy, this researcher developed a specialized hardware device, the PC Moderator, to help monitor and limit game play time when moderated limits could not be maintained otherwise. Approximately 1000 devices were sold from 2005 to 2015. It locked on the desktop computer and could be used to monitor how much time was spent on the computer and to set hardware enforced time limits. Since the device reduced the amount of computer time directly, reduction in gaming time was seen as a successful treatment outcome. However no data was collected on its long term effectiveness. Follow up with a limited number of cases suggested that use for an extended time (>12 months) resulted in positive outcomes (self, parent and clinician report of remission from gaming addiction). However since the outcomes cannot be directly linked to treatment, this must be viewed cautiously. Due to compatibility issues and evolving technology the product was discontinued in 2015. However based on the experience with this device, a new device - an entire small form factor gaming computer has been developed. It provides far more capabilities than the PC Moderator allowing remote limit setting configuration and use data collection. It is hoped that research conducted using this computer will help provide clinical validation of the methods proposed in this paper.
Reducing Complementary Rewards
There are a number of complementary rewards associated with computer game play. Often these complementary rewards come from the technology itself. Parents would be counseled to not buy new or better gaming equipment or allow their child to build their own computer or purchase new accessories related to gaming (i.e. advanced controllers). Parents would seek to inform other family member as well.
Increasing Competing Rewards
As less time is available for gaming and more time is spent on competing activities (homework, employment, socializing), it is hoped that these activities will become sufficiently rewarding (i.e. better grades). Parents would be counseled to find new enrichment activities for their child. If necessary, limited extra computer/video game time can be used to motivate the initiation of competing activities. It is likely that preference for alternate activities will not be immediate and it may take time to see increases in certain behaviors. Older gaming addicts must find meaning and purpose in their life and pursue new or revived passions that, over time, will offer more significant rewards than the gaming. Career assessment/counseling, individual, family and marital counseling are but a few ways to help clients through this life transition.
Summary
This paper presents a novel behavioral treatment approach using a harm-reduction, moderated play strategy to treat computer/video gaming addiction. This method involves the gradual reduction in game play time as a treatment intervention. Activities that complement gaming should be reduced or eliminated and time spent on reinforcing activities competing with gaming time should be increased. In addition to the behavioral interventions, it has been suggested that individual, family and parent counseling can be helpful in supporting these behavioral methods and to treat co-morbid mental illness and relational issues. Although these treatment methods have significant face validity (i.e. lowered play times) and years of clinical application by this author, it has not been independently evaluated.
Declaration of Interest
The author is part owner of Sentinel Gaming Systems, the firm developing the computer system described in this article. It is intended to be used for treatment and research related to the behavioral treatment approach presented in this paper.
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