Is pathological game addiction a real phenomena we should be concerned about, or something cooked up by the news services as the latest scandalous story to report? In this piece, I will take seriously the charges against digital games in terms of the destructive effects of pathological addiction, and offer a practical approach for dealing with this issue going forward.

Pathological Gaming

It is futile for anyone to argue that digital games are not addictive, given that for as long as we have been making them we have praised games precisely for their addictiveness – indeed, in the 1980s some videogame magazines used “Addictiveness” as one of their scoring criteria when reviewing games. But this flippant use of “addictive” is of the same nature as when we complain that processed potato snacks are “addictive” (after all ‘Once you pop, you can’t stop!’). We need to be as clear as we can about the distinction between compulsiveness and destructive addiction if we are to understand this issue, but to do so we run up against a major issue concerning the role of medicine in modern culture.

As Ivan Illich has criticised at length in Medical Nemesis (a book taken very seriously by the medical establishment), the medicalisation of life that has developed over the previous few centuries has transplanted the responsibility for life and death away from the individual and into the hands of medical professionals, whose decisions are afforded greater authority because of the role of scientific research in underpinning their attitudes. However, this perspective ignores a variety of problematic situations that result from individuals being disempowered from their own wellbeing and, as Illich forcibly argues, the medical establishment is quite capable of causing considerable harm in its pursuit of health.

This is not the place to pursue Illich’s arguments in depth, but it is important to the current discussion to recognise Illich’s point that as soon as life is seen in terms of disorders that differ from normal functioning we invite the creation of a proliferation of categories of dysfunction to be “treated” – the responsibility of the individual to take care of themselves is superseded by an assumption that when one is “sick” one must go to doctors for “treatment”. To question the merits of this perspective is not to dispute the power of medicine to heal disease or infirmity, but rather to challenge the assumptions concerning what we shall consider “sickness” in this sense. This issue is of crucial importance to the question of pathological addiction.

Considerable dispute exists over “whether game addiction exists”, by which people typically mean whether or not videogame addiction is a disorder that meets the criteria for inclusion in a diagnostic manual, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. But if we put aside our distinctions between one kind of game and another, we will immediately be forced to accede that game addiction is already a recognised pathological disorder, namely Pathological Gambling. The DSM-IV states that the criteria for this disorder is a minimum of five out of the following ten symptoms:

1. Preoccupation. Frequent thoughts about gaming.
2. Tolerance. Greater or more frequent gaming required to experience the same rush.
3. Withdrawal. Attempts to cease produce restlessness or irritability.
4. Escape. Gaming is used to escape problems in real life.
5. Chasing. Big losses result in intensified gaming to try and win back what’s been lost.
6. Lying. The extent of the habit is hidden from friends or family.
7. Loss of Control. Attempts to reduce gaming are unsuccessful.
8. Illegal acts. Theft, fraud etc. pursued to raise funds for more gaming.
9. Risked significant relationship. Continuation of the habit even after risking or losing a relationship, job or significant opportunity.
10. Bailout. Turning to friends or family for financial assistance as a result of gaming.

These criteria were written about gamblers, of course, and (5) doesn’t transpose well into digital games or compulsive board games like trading card games (e.g. Magic: The Gathering). Nonetheless, if you take the typical World of Warcraft “addict” then meeting five of these criteria isn’t exactly difficult. A student who drops out of University to play WoW fulltime almost certainly meets criteria (1), (3), (4), (7) and (9). Recall the speech in 2008 by Federal Communications Commissioner Deborah Taylor Tate that declared that “one of the top reasons for college drop-outs in the U.S. is online gaming addiction — such as World of Warcraft”. The boundaries between gambling and gaming gets narrower the more effective we become at making our games “addictive”.

It is for this reason that I see it as an extremely dangerous move when news reports that focus on “videogame addiction” (i.e. pathological gaming with digital games) feature advocates trying to defend the medium by saying that there is no recognised medical condition for this kind of addiction (as Ian Livingstone stated in the recent Panorama report, and many others have done on different occasions) since this is to stake the status of the medium of digital games on the whims of the medical community. If the medical community changes its mind (as it does with considerable regularity) we could be left up a certain creek without suitable implements. Do we really want to gamble that the next edition of the DSM, due in 2012, will not recognise pathological gaming as a disorder distinct from pathological gambling?

Escape to Fiction

Two weeks ago, I wrote about The Power of Games, adapting philosopher Noël Carroll’s work on the success of movies as a medium to digital games. The two key points of discussion were the extent of widespread engagement (i.e. how many different people can enjoy the medium) and the intensity of engagement (i.e. how strongly the medium captivates attention). It is this latter issue which is of key importance to the topic of game addiction, since digital games can produce an intense engagement that far exceeds that of a movie, which Carroll notes is more effective at sustaining engagement than a book. But it’s worth noting that even a book can captivate addictively – we use terms such as “page turner” and phrases like “I couldn’t put it down!” precisely as a means of praising books, just as gamers applaud titles that succeed in being “addictive”.

Modern culture is addicted to fiction – or perhaps I should say habituated to fiction. We scarcely think twice about the amount of television or films watched, the number of novels or comics read, the volume of songs listened to, the sheer extent to which fiction occupies our attention and provides our most basic forms of entertainment. Since even sport can be seen as a kind of fiction, the cultural role of imaginary media is so vast we tend to be completely blind to it. Games, digital or otherwise, are another form of entertainment fiction that we can choose to enjoy, and as such, there is no cause for alarm when someone chooses to play a game instead of watching TV. All things considered, there are a great many games that are more educational, more aesthetically interesting, or more culturally valuable than a typical soap opera or some equivalently compulsive content in non-interactive media. We don’t panic when someone tunes into a reality game show every week, even though their interest in the show might border on the obsessive.

The problem with modern digital games isn’t that they can be as or more compelling than other media (at least for those players with the skills to tackle them), but that the duration of play can attain disturbing scales. A movie might enrapture you for a couple of hours, you might read a novel feverishly over the space of a few days, and a TV show might hold your attention for some twenty hours over a year, but none of these things are likely to disrupt your life significantly. Conversely, a World of Warcraft or Call of Duty player might rack up 20 or 30 hours a week for a year, or indeed for many years. It is because the volume of time that can be sunk into the fictional worlds of games approaches the infinite that destructive addiction is plausible for this medium but largely implausible for movies, television or novels.

This is not to say that everyone who plays these games will destroy their life – this is utter nonsense. Most players of online games live perfectly happy lives, and the time they spend playing merely constitutes a particularly enjoyable hobby. The vast majority of digital games for the overwhelming majority of players are utterly insignificant causes for concern. I played Pokémon for perhaps a hundred hours in what I am happy to call an addiction, but eventually I stopped. I may blame it for some insomnia, but it certainly did not cause any lasting harm (although I have been reluctant to play another title in the series since, simply because I don’t have the time). A handful of games, and a couple of MUDs at University, have tied up significant chunks of my time like this, but never in a way that has prevented me from living my life, and the same is true for millions of gamers.

We sometimes get into trouble when thinking about game addiction because of the tendency to think of things as being “addictive” (e.g. “heroin is addictive”), which misleads us as to what is actually involved in pathological addiction. True, heroin can be (as the comedians quip) “quite more-ish”. But plenty of medical patients receive equivalent opiates for pain relief without forming a habit. A serious drug habit develops not just because the substance being abused is physiologically and psychologically addictive but also because the person in question uses the drug to escape their situation – hence the prevalence of destructive drug habits among impoverished urban communities. So it is with digital games. Yes, they are addictive, but problem gaming doesn’t happen because games are dangerously addictive things, but because the player in question flees the real world for a better life in a fictional world. As Edward Castronova and Jane McGonigal have argued, if the exodus into fictional worlds demonstrates anything it’s that the real world is “broken”, although they don't necessarily agree as to what this should mean.

In 2006, a clinic opened in Amsterdam to treat compulsive computer gaming. It eventually closed its doors, claiming that ninety percent of the young people who seek treatment for gaming addiction were not addicted, and that compulsive gaming should be considered a social not a psychological problem. In a story reported by the BBC in 2008, the founder of the clinic, Keith Bakker, stated:

These kids come in showing some kind of symptoms that are similar to other addictions and chemical dependencies. But the more we work with these kids the less I believe we can call this addiction. What many of these kids need is their parents and their school teachers – this is a social problem.

Similarly, a report out of Singapore last week claimed that one in ten students in that country were “videogame addicts” but stated that the kids in question were already suffering from social problems that obsessive game playing simply exacerbated. One critic of the study stated it was probably measuring preoccupation not addiction, and touted the usual line about the lack of an acknowledged diagnosis for the disorder, but this is beside the point. Disputing that pathological gaming can occur shouldn’t be focal point of this debate, else we will cede our right to debate the issue to medical experts whose labelling of “disorders” can be extremely suspect, particularly when lucrative pharmaceutical money is on the table.

The last time I was living in the US, I was shocked at the way commercials for pharmaceuticals offering treatment for “restless leg syndrome” were repeatedly aired on television, encouraging anyone who had difficulty sleeping to ask their doctor to prescribe the relevant pills. Many doctors have publically criticised this kind of “disease mongering”, and castigated not only the pharmaceutical industry for lighting the fire but also the news media for fanning the flames. When “treatment” is big business, impartiality as to what constitutes “sickness” becomes difficult to attain, and medical categorisation loses any credible claim to objectivity. This is part of Illich’s critique of medicine that is as true today as it was when he wrote Medical Nemesis thirty five years ago. Similarly, when “play” becomes big business, the probity of companies that supply it needs to be subjected to scrutiny, but the news media’s penchant for melodramatics cannot be permitted to make mountains out of molehills.

Conclusion

We do not need and should not want doctors to render judgement on digital games as a medium, but we who work in the games industry do need to be honest and forthright about how the artworks we make can be abused. Just as poverty is the hidden cause of heroin addicts, social problems are the hidden cause of pathological gaming. Lonely, withdrawn, socially inept or phobic individuals, people whose lives don’t quite come together, or those who suffer a major setback, can all fall into digital games as a crutch that can become pathological, hiding away in fictional worlds from the situations they are fleeing from. These are real problems that isolated individuals are facing, and bringing in the medical community to police this issue isn’t going to help resolve them.

I am tempted to suggest that those of us that make games have a duty to help those who end up abusing them, but I doubt it’s practicable for us to do so. For a start, such people are by nature of their circumstances invisible. The very few incidents of online gamers dying under tragic circumstances were difficult to prevent precisely because the people in question lacked a supporting social network of friends and family. The erosion of community that has escalated over the last century has brought about serious issues that we have largely ignored, in part because of a tendency to think of problems in terms of diagnosis and prescription, not in terms of responsibilities, relationships and society. Illich’s critiques of the modern world have not lost their sting: when we hand over all our crises to experts, we absolve ourselves from any duty of care and turn a blind eye to our collective troubles because they we have decreed that they are ‘somebody else’s problem’.

We ought to think carefully about how we are using the escalating reward schedules that help create compulsive digital games, and in particular about creating games which can be played for indefinite lengths of time. Commercial success cannot be the only criteria by which we judge the medium of digital games if we want to be taken seriously as an art form, and neither can legions of doting fans be taken as absolution for marketing a game that can be all too easily abused as an escape from reality. When companies do not behave responsibly, the law is eventually called in to intercede. Because it is recognised that pathological gambling can be a problem, casinos operate under stringent regulations. If we do not want to suffer similar restrictions in the future it behooves us as an industry to be responsible about access to those game mechanics that we know can be addictive and that may lead to pathological gaming among a small minority of vulnerable individuals.

Agree? Disagree? Share your views in the comments!