Video Game “Addiction” Treatment: Dr. Brett Merrill On What Really Works

A few weeks back, I wrote about my own history of playing video games rather excessively. As a result of that article, I got a lot of inquiries from people who asked for help and strategies that go beyond what I described. Questions ranged from how to deal with a child that plays seven to ten hours a day, to a student who considers himself addicted to the same game now for more than ten years.

I’m no clinical psychologist. Thus, I set out to find one who ‘gets gamers’ and would be willing to share some advice. My main concern was to get professional input on how to handle compulsive and excessive gaming, learn about how psychologists deal with it (as well as at what cost), and what some strategies are that people can ‘try at home’.

Through a researcher on gaming behavior, Joe Hilgard, I found Dr. Brett Merrill, a psychologist who did a lot of research on video gaming “addiction” himself and who he kindly agreed to be interviewed about possible ways to handle it.

This is a phone interview I did with Dr. Brett Merrill on February 16th. It has been edited for ‘print’.

About Dr. Brett Merrill

Karsten: Brett, can you tell me a bit more about who you are and what it is that you do?

Brett: I’m a licensed clinical psychologist in the state of Utah in the United States, and I have an emphasis in my training in working with kids and families. It’s kind of an interesting mix.

Right now, I’m actually doing something unrelated to my research interest. I’m working with a company called New Haven Residential Treatment Center. It’s a site where adolescent girls will go and live for about a year or so, if they’re experiencing emotional and behavioral issues at home or are not able to stay safe at home.

I do all their psychological assessments. That’s things like the IQ testing, personality testing and psychopathology testing in order to look for depression and anxiety. In addition to that, I teach adjunct at Brigham Young University in Provo, Utah, part-time. I usually teach clinical courses, including clinical psychology, going over the different modes of therapy, or things like abnormal psychology, where we discuss the different disorders there are.

But before that, my research or my interest in working with video games came when I was going to my school for my doctoral program. It was something that I was highly interested in, but I couldn’t find anyone that would mentor me because no one else had enough experience in that field, or they weren’t taking new students at the time. That’s why I did my dissertation on something completely different but spent a lot of my spare time researching video games and what makes it harmful or what’s helpful when you feel stuck.

Real Life Gaming “Addiction” Cases

Karsten: One of the inquiries I received after I posted an article about video gaming addiction is actually one of the parents of a 14 year old boy who, according to them, is playing about seven to ten hours a day now and doesn’t really do anything else except go to school, play video games, sleep, and fight with his parents when they’re trying to reduce his game time or try to criticize him in any other way.

They are very reluctant to remove physical access to the game, because there’s a lot of Internet cafes, and they’re worried he’ll just play there. What do you usually advise parents to do in those situations?

Brett: That’s a really tough one, because they could do lots of different things in the home to limit it: by cutting off access to the Internet or just limiting screen time. But you’re right, with Internet cafes, he could just go there, and those usually aren’t the best environments to be in anyway.

I don’t know if there’s a great solution at this point where you can just jump in and make some radical changes. What would probably be easier for the parents is to discuss their plan in advance and tell him some of the things that they’re wanting to do and why they’re wanting to do it, and then making more slower or gradual changes in the boy’s life.

One thing that’s tricky, though, is if he’s spending that much time on games, I’d be curious to know what type of games that they are. Just because I know that some MMORPGs (‘massive multiplayer online role playing games’) have a very high social component to it. It could be that he’s just going in and connecting with his friends and feeling pretty satisfied, actually spending a lot of time online with friends. It’s going to be hard to change that, because it’s not just a game but also a social system.

Karsten: He does seem generally happy playing the game. The game in question is a MOBA (‘multiplayer online battle arena’): very competitive and, similar to MMORPGs, social interaction-based. 

Virtually all messages I receive about excessive gaming were related to games where there is a social factor or competitive factor to it – especially MOBAs and MMORPGs.

Brett: Right, where they’re kind of needed for teamwork or have those connections there. That’s been a big shift for games and has been one of the things in the research that makes it even more addictive. It’s not just gaming by yourself – like playing Mario Bros. – but it really is almost like a team sport, and so there’s that social piece that really draws people in.

Karsten: One plan they were considering is to just change the environment entirely and send their son to a boarding school that’s focused on helping teens with overcoming issues. What are your thoughts on that?

Brett: It’s tough. In the clinical field, we like to try the least restrictive environment first. Going from him being home and going to school, jumping right into some sort of boarding school could be really helpful for him and kind of create this jump-start for him. But usually, parents will try an intermediate step first.

This could be going in to a counselor maybe once or twice a week and being able to talk through the issue there, or doing some family therapy or individual therapy. Because there may be things that they can do that are much cheaper and possibly just as effective that don’t require as much change for the individual. But if they’re trying that and still just not seeing any success over a period of a few months, then that can be a next step.

There’s a few programs out there, more so in South Korea and Asia in general, that will work very specifically with things like excessive Internet use or even excessive gaming. I remember there being over 140 counseling centers that work with Internet addiction in the country. I went to a conference just this last week where someone mentioned over 500, but I’m not sure if that really is the case.

Karsten: I also received an inquiry from a 22 year old who’s about to enter a four year degree program. He has been playing RuneScape, an MMORPG, for ten years now on and off.

He plays it, gets drawn in, plays for a few years, gets upset with the amount of time he spends, quits, and when he tries it again, he’s immediately drawn in again.

What do you tell young adults who have this issue: the moment they touch a game, they’re done?

Brett: Some of the latest statistics I’ve seen are that the average gamer is somewhere between the ages of 33 and 35 years old, so it’s certainly a very common occurrence. We usually think of it in terms of teenagers, but a lot of adults are having this type of struggle.

What’s common? I’ll talk about this. What we normally see is these periods of binging. Someone will be playing a game for a long time, and they finally recognize that it’s gotten to an unhealthy level for them, and they want to make some changes in their life. Usually, they can do it pretty well. Sometimes it only lasts a few months, and sometimes it’s a few years, which can be really great. And then they’ll find themselves drawn back into the game or a similar type of game, and then they feel now, all of a sudden, like, “Oh, this is a huge failure. I tried to quit this once. Now, I feel myself locked back into these old habits.”

What we see is not just a change in behavior, but there’s also a change in the way that they’re thinking about it, too. They’re kind of trapping themselves into a box, like they’ve gone over a cliff almost, and it’s going to be really, really hard to return.

When you’re able to take a step back from that, yes, we want to be careful of engaging in problem behaviors, especially old patterns where we know we’re kind of weak or we feel like we get trapped. But we want to be just as careful to be mindful of our thoughts, where we’re not making these very black and white conclusions about game playing. But we kind of say, “No, this is okay. Yes, I’ve gotten back into the game, but I didn’t play it for two, three years. I felt really good about that time. I think that I can do that again.” It’s just a different approach in the way that we even think about ourselves.

Karsten: If someone says they don’t play a game for three years, and then three months they’re absolutely immersed and do nothing else, you would also lean towards saying, “That’s okay. You have these binge phases, and then you return. And as long as it doesn’t dramatically impact your life long term, it’s okay, and you should just accept yourself that you are that way.”

Brett: Right. It’s not condoning anything that they’ve done. Yes, maybe they still view it as a mistake, or maybe they still view it as not the direction in their life that they want to take, but it’s not the end of all of their choices. They’re just recognizing it, saying, “I can still choose right now what I want to do.”

It takes a very different mindset, recognizing it for, “Yes, I’m getting too involved once again, and this isn’t the direction I want to go in. So let me make some changes now.” Versus, “Oh, I’m trapped. I’m falling back into old patterns,” kind of making this a permanent thing in their mind.

How to Deal With Excessive Gaming

Karsten: Do you have some go-to advice you want to give to people who feel they play too much?

Brett: One thing that’s really helpful is to find out what the end goal is. One thing that I often hear in therapy is people saying, “I can never play games again. I know for me it’s just a destructive weakness,” and so they avoid games at all cost.

That can work for some people, but for the majority of people, what we find is that taking that type of stance actually just sets them up to fail again. It becomes this all-or-nothing deal. Any time they go back to a game, even for maybe an hour, they feel like they’ve slipped back into those old patterns once more. And they’re more likely to do the binging at that point and feel more trapped, more stuck, instead of getting out of the cycle.

Versus someone who maybe says, “Well, I feel like I play too much, and I want to have balance in my life.” Like, “I need to go to school,” or, “I want to hold a steady job or spend time with my family. And it’s a matter of finding balance. So how much time a day is okay for me to play? And can I give myself this allotted time where I can do fun things?”

Because it is enjoyable, and it is spending time with friends. But also, just like you would outside of the world of games, you probably wouldn’t go spend ten, twelve hours a day with friends playing basketball or something, because your body physically gets too tired to maintain that. Even though it is fun and enjoyable, it’s finding that balance that they want in their life. That’s about some of the biggest key things I would say, is having someone think ahead of time what they want their life to look like, and can they balance some games with that or not?

One of the other things I think is really helpful for people is to actually track the amount of time that they spend playing games. Usually, we look back at our time saying, “Oh, wow, I just wasted a few hours.” And maybe if they are tracking the amount of time very specifically, they find out they’re spending a lot more time playing games than they thought they were. And that helps increase that awareness of how impactful it can be, especially for teenagers, who maybe don’t have a great sense of time as it slides by, or they’re bored doing something else like homework, which is far less rewarding. But just tracking where they spend their time each day can be really helpful, I think.

Karsten: Years back I went into weight loss. I tried to lose some weight, and one of the things that I noticed helped a lot was just tracking the calories I was eating, just to see, “Okay, this is a lot,” or, “This is not a lot.” It gives you a bit of a feeling for it.

Brett: It really kind of opens your eyes a little bit.

Karsten: One of the things I find really interesting is that you say you’ve got to find a balance, and quitting completely or not playing at all just sets people up for failure. That sounds very different from the kind of advice I thought you would give to someone who has a substance addiction. I’m no expert for that, but from what I hear, people who suffer from alcoholism, they’re advised not to drink anything at all whatsoever.

Gaming vs Substance Addiction

Karsten: I was talking for this article with other academics, and they were keen to make the distinction that video gaming is not really yet confirmed to be an addiction in academic circles. They’re wondering if it might just be a disorder.

Does it matter for individuals if they’re suffering from a disorder or an addiction? And how is that different from, let’s say, a substance addiction?

Brett: We use the term addiction, and we usually feel like we have a pretty solid idea of what that means. But professionals, both in academics and research, and kind of the people who set the guidelines for what disorders are, never use the word addiction. So that’s in like the Diagnostic and Statistical Manual 5, or the DSM-5, or in the ICD-9, which is another classification system used worldwide. You won’t see the term addiction at all.

You see the term substance use disorder or Internet gaming disorder. And one of the reasons why they do that is because there tends to be a stigma that comes along with the word addiction. We think of it as someone feeling powerless or that they have very little control over what they’re doing. So by separating it and calling it a disorder, we’re saying that there are a certain number of criteria that are problematic, but it’s not necessarily deterministic in their lives. It’s something that can change over time.

The label tends to matter, or at least, we think that the label matters. But realistically, the way that we go about treating it is going to be very similar. The only thing I would caution with this is what we think of substance addiction or substance use disorders: there’s popular treatments like Alcoholics Anonymous or 12-step groups that help people through this and change their lives. And for some people, it’s extremely helpful.

But, again, this is an area where we see relapse rates being very high. So people will be sober for a certain number of months or years, and then they find themselves slipping back into these old behaviors. And there’s usually that crash that comes along, and it’s really hard to build themselves back up. Because the philosophy has been, “Not a drop. Not even one time.”

And so what it does is build up this idea of, “If I can’t do it at all, then any little mistake I make is a really big mistake,” versus if it’s more of a balance and, “I’m okay with some of this, but not okay with this,” we kind of give ourselves permission to make similar mistakes. And overall, the results tend to be better. We see a lot fewer relapses with that kind of mindset. So whether it be in substance use or video games, the results can be about the same.

Karsten: Would you point gamers towards finding more balance rather than going with something like a 12-step approach?

Brett: For most people, I think that works best, yes. Finding the balanced approach is going to be far more helpful in the long run. But even with that being said, there are a few people I think where the complete abstinence is the most helpful approach. I’m not sure what the difference is yet.

Gender Differences in Addiction

Karsten: Right now, you’re working mostly with adolescent girls and their families. Do you see a lot of video game issues there as well?

Brett: Actually, no.

Karsten: Not at all?

Brett: It’s really rare. We had a little over 100 girls come in this year, and I think of those 100 in this last year, I had maybe two or three which pretty closely matches what the research says anyway. We’re only looking at maybe about 8.5% of the population really having a hard time with video games, and usually, with girls even less so than boys. Boys tend to have more of a problem with the addiction part.

Karsten: Do you know why that is? Do you have any guesses?

Brett: We see similar things with substance use. We see far more males using substances. And the way it splits in the clinical world is males tend to be more external in terms of regulating their emotions and managing their moods, they tend to be more aggressive, or they tend to use outside sources to regulate their emotions.

So either eating or exercising is going to work really well for males. Whereas, for females, they tend to be more internal, so usually you see more of the mood disorders, things like depression and anxiety. They tend to implode rather than explode. I think what we’re seeing is just the same thing here with Internet gaming disorder: males are tending to act outward as a way of regulating their emotions, whereas girls may do that more internally.

When to Seek Out a Therapist

Karsten: Most people in my experience are reluctant to seek out professional help, whether it’s for stigma, whether it’s because they don’t understand it or whether they just don’t trust it. They think, “What could possibly the benefit be if I can’t do it myself?” At what point would you recommend people to seek out professional help?

Brett: There’s two main things that I look for, and then a lot of little things that go along with that. It’s important to look for the amount of time being spent. There’s some pretty solid research saying that if people are spending upwards of 20, 25 hours a week playing, then that’s highly correlated with problems in their lives. And so just the amount of time spent can be a pretty good indicator of it becoming problematic.

The other piece goes along with that, but it’s slightly different. It’s the idea of functioning. So, “Am I going to school and getting good grades still, even with playing a lot?” Or, “Am I able to go to my work, and I arrive on time? I feel like I’m able to think about my work when I’m at work. I’m not thinking about other things, like video games.”

And then relationships is the last one. Where, “Can I be connected to other people in real life?” Although virtual reality is good, too. But just this idea of, “Can I connect with other people? Can I talk, or does it feel this awkward, because I’m not practiced at it? Or I can only talk about video games, versus talking about a variety of subjects?”

So the amount of time spent and functioning are the two biggest ones. Although, like I mentioned, there’s a lot of little things in there, like if they’re spending a lot of time thinking about the game or going online and reading the forums, and being involved that way. If they’re very irritable, they’re anxious or sad when they’re not able to play, kind of changing their mood in that sense, or if they find themselves needing to play the game more often or doing more extremes in games, maybe that’s a negative indicator, some things like that.

Karsten: If you see someone post on the Internet about their gaming addiction, at what point do you say, “Well, maybe just try a few of these things yourself first”? And at what point would you say, “Yes, at this point you should definitely be talking to a therapist”? 

Brett: I think there’s a lot of people that can work through it on their own and just check themselves. The point when a therapist might be more helpful is if the person is getting feedback from friends, or parents or loved ones that they’re spending too much time playing games. If they do, it probably means that they are.

Now, everyone has a different viewpoint of how much is okay, and so you think it’s differences of opinion. But if they’re getting that opinion from multiple people, it’s a pretty good sign that it’s impacting their life in ways that they’re not recognizing or that they’re minimizing, because they don’t really want to recognize it at that time.

Therapy Methods and Cost

Karsten: If they seek out a therapist, how does that usually work? Do they see them once a week, or do they get immediately referred to an intensive program?

Brett: This really depends on location for the person. I think most places you can go to, at least in the U.S., it’s kind of a standard, once a week type of therapy. Going in for maybe a 50-minute session once a week is pretty standard. If it’s really problematic, maybe they’re doing twice a week in the beginning, and then you taper off the sessions over time.

However, there are some people who maybe if they’re playing 35, 40 hours a week and really…well, let’s say 40-plus hours a week, so the equivalent of a full-time job plus, maybe something more intensive would be required at that point. Like I mentioned, there are certainly some centers in South Korea and Asia in general that do this.

There’s more popping up in the United States. In this conference that I attended last week, I heard about a program in Washington called the reSTART Center. This is exactly what they do. They specialize in taking people who consider themselves to be addicted to the Internet, or social media, or texting, or just technology in general, including video games. And they’ll go and live there, and practice other ways of seeing the world and going tech-free at the beginning, and then learning how to integrate that as they get further on in the program, so that by the time that they’re done, they feel like they have more of that control in their life.

Karsten: People might be also worried about the cost. I assume rates can vary. But, let’s see, if someone sees a therapist once a week for this 50-minute session, how much do they have to budget for that?

Brett: Again, it depends on location, and who they’re working with, and if they have insurance or not. But one thing I’d expect is it would probably be somewhere between $100 and $120 per session without insurance helping with that piece. Beyond that, it just depends on the insurance and some things like that.

Karsten: How many sessions do they usually have to take? Is this something that goes on for a year, or is this something that after three months, you are already at a point where you can say, “Half of the people are already done,” so to speak?

Brett: Yeah, it really depends on how severe the case is, but most cases are going to be somewhat mild. So maybe something like a 12-week thing would be sufficient, but there’s going to be some cases that are definitely more severe and maybe taking, I don’t know, six to eight months.

In outpatient therapy, the weekly therapy, if it’s taking upward of eight months, there’s actually good review for saying that they’re probably not going to change a whole lot more as a result of therapy. And so they might want to try something more intensive, if they’re still not getting good gains or making the progress that they want.

Who You Can Consult

Karsten: Do you currently offer treatment or consulting for people seeking help with an Internet or video games addiction or disorder?

Brett: With my case load right now, working full-time at the center, I don’t have time for private clients. But I’m always helpful to consult with people, help them find some resources that are open to them. And I know people, at least locally, a little bit less so nationwide, but there are some who I would trust to work with and refer people to.

Karsten: Brett, thank you very much for sharing your views on this. This has been very helpful and interesting, not only for the people who are reading this, but also I myself can relate to a lot of those points.

It’s interesting to hear about the hours per week figure, because I definitely was myself in the top end of being above 40 hours in a week at some point. It’s really interesting to see the strategies you’re recommending, from tracking time to also just seeing what the other people around you are saying.

For a lot of people, this is a substantial amount of money to spend. But I also imagine that for most, if they compare the impact it can have on their life, the improvement they have, if it seriously should, it seems like it’s really going to be a big help for them to seek out professional treatment if they are at that stage.

Brett: And usually, the earlier you can intervene the better, right? You’ve probably seen things in your life, if you had kind of stepped in and done things earlier on, you would have been able to spend that time doing many other things. And it was cool reading through your blog from last time, that you had figured out so many of the strategies that the research shows to be helpful on your own. You were able to switch some of your behaviors to doing more exercise and working out that way. It can be a really great outlet. So I was impressed to see that you had done that.

Karsten: Thank you very much!

Brett: Well, thanks, Karsten. I appreciate your time, too. I love what you’re doing with this, helping people out.

Sometimes It’s Not Just Games

After my interview with Brett, he sent me an e-mail with an additional point he wanted to add:

Those who struggle with regulating how much time they spend playing video games usually also have difficulty with emotional or psychological problems (e.g., depression, anxiety, substance use, social phobia, etc). Most of the solid research out there seems to suggest that depression and anxiety come as a result of spending too much time playing video games, though the opposite effect could be true, too. It could be that people immerse themselves so fully in games as a way of escaping seemingly overwhelming problems in their real life (e.g., mounds of homework, job stress, rejection in relationships). It’s important to focus on all aspects of a person’s health, and not just one problem area, like video games. People are complex, and the more we understand the full picture of what is going on in someone’s life who is struggling, the more we can be motivated by love and compassion to help them make healthy changes.

My Take Away

What I found really interesting about this interview is Brett’s ‘balanced’ approach to dealing with excessive video gaming. Rather than stigmatizing it and advocating total abstinence, he favors a kind of self-acceptance and achieving a balance that allows people to lead a fulfilled life without having to entirely give up one of their favorite hobbies.

His advice on writing down your exact gaming times as a first step when trying to play less strikes me as something that anyone can implement at home. If you right now feel that you’re playing too much, this is something you can start right away with a pen and a piece of paper. Just keep a detailed log for now – you don’t even have to change anything – and track your time as you spend it.

Seeing how relatable Brett was for me made me understand why a lot of people say that the most important aspect of therapy is finding a therapist you really jive with. A study on how psychotherapy works seems to reiterate the importance of the bond between therapist and patient. In case you had a more negative experience in the past, it might be worth looking into finding a therapist you get along with better.

Coming Soon…

Brett mentioned reSTART – a center in Washington that offers a 45 to 90 day program to help participants overcome their gaming addiction. Hilarie Cash, the co-founder and executive director of reSTART, agreed to an interview which I will be publishing soon. Subscribe to the blog (on the left side) to be notified when that is published.

In the mean time, you can ask any questions you have about video gaming addiction in the comments below or sent me a message via my contact form.