interview: Dr. Hilarie Cash of reSTART Internet Addiction Recovery Program

Mike Schramm
M. Schramm|09.09.09

Sponsored Links interview: Dr. Hilarie Cash of reSTART Internet Addiction Recovery Program

We've talked about Internet addiction before a few times here on the site, but it's always been through the lens of the media. Certainly there are players of WoW and other games out there who play the game so much it's affecting their lives, but most of the cases we've heard about have been a little over the top -- parents crying that their children are lost, kids playing nonstop and picking up bad health and social habits from this horrible game.

And so, when we heard that there was a new center opening for Internet and gaming addiction in Washington State, we decided, instead of just listening to the media reports, to sit down with the co-founder herself and have a more thoughtful conversation about gaming addiction: how and why it happens, how they're trying to fight it, and how it's portrayed, from both a media and a gamers' perspective. Dr. Hilarie Cash has been working with Internet addicts for 15 years -- she's the cofounder of two different addiction clinics, including the new reSTART Center, and the co-author of "Videogames & Your Kids: How Parents Stay in Control." You can read our exclusive interview with her by hitting the "Read more" link below. So I guess the best place to start is probably at the beginning. What's your background -- how did you guys get started when you kicked off the center?

Dr. Hilarie Cash: Well, my own background is -- Internet addiction is something I've been specializing in for 15 years. Ever since I had my first video game addict in 1994, I guess, who was addicted to a Dungeons and Dragons online game, text only.

Was it a MUD?

Yeah, it was a MUD. And so, that window into his problems, and the community that he was playing with, I guess I just inuited back then that I was seeing the trickle before the flood, and so I started looking around and finding out what other people in the mental health field were noticing this and writing about it. And back then in the '90s it was Kimberly Young, David Greenfield, Mersa Orsack, and that was almost it. Very few people in my field were writing about it or doing any research. And then, ten years ago in 1999, I started a company, I co-founded a company with Jay Parker called Internet/Computer Addiction Services, and that was all outpatient. We have a pretty well developed outpatient program for sex addicts and their partners, and then I always maintained publicly, because I have a son who loves video games, that I was really interested in the issues of video gaming.

What was really attracting you to it, as compared to the other types of psychological issues and addictions that you were dealing with?

Well, I was interested in all of it, it's just that I could really see the power of the video games. I already knew the power of porn and all of the sexual content on the Internet, so I was interested in all of it, I've been working broadly. But again, because I had a young child who was drawn to video games, and it was so much what all of Luke's friends were doing, that I was just particularly interested in that, because that was the thing that was grabbing young kids, more than the rest of the Internet, it was that that was grabbing young kids. So I was really interested in how that was impacting kids developmentally.

So you say that was all outpatient stuff, and this center now is the first inpatient center to do this type of thing?

Right. I was very frustrated that there was no place inpatient that was really set up specially to deal with Internet addicts. And then Cosette Rae, who is herself a therapist, contacted me just five months ago, and wondered how we might work together, because she's also been dealing with this problem and is very attuned to it. And I just complained to her, like I often have complained about the lack of inpatient opportunities, and she said well my husband and I have been developing our property as a retreat center, and perhaps this is what we should do it with. So it was just a happy chance meeting, really, that worked. So we very quickly were able to get the program up and running, and our first client started at the end of July.

Oh, the end of July. And that's kind of what's happening now is that we've seen a lot of press and a lot of things covering the opening of this center. Now, Internet addiction as a term, or as an actual diagnosis, you've been working on it for a long time, but as an actual diagnosis, it seems like it's still being sussed out in the official medical community. Certainly, addiction is a very clearly defined problem, but Internet addiction itself, there's still some discussions going on there, right?

Oh yes. Here's what's kind of happening, the trend that's going on. They're working on the next version of the diagnostic manual that clinicians use.


Well, we've got the DSM IV, they're working on the DSM V. And what we are pretty sure about is that they are going to have a category for substance use addictions, and non-substance use addictions. And the question is what is going to be included under that category for non-substance use addictions. We are quite sure that gambling will be there because the weight of evidence has been accumulating over decades, you can't argue against it, there is such a thing as a gambling addiction. But whether or not IAD, or sex addiction or videogame addiction, we don't know if that body of professionals whose making those decisions is convinced that there's going to be enough evidence, through research, to be able to include IAD. It has to be based entirely on the weight of research, and this is a fairly new phenomenon, and research is a slow moving animal. We are in hopes that it will, but we don't know for sure.

What does that mean? If it doesn't show up in the DSM V under non-substance abuse, I mean there are certainly people out there who play games so much that it affects their lives, what does that mean if it's not in the manual?

It means it's too early, it just means that the research hasn't progressed to the point that it gets to get included in the manual. And it means that the next version of the manual will probably include it. Here's the thing that they're looking at, in particular. The direction that all of the mental health field is taking, is toward really understand what's going on in the brain. When you've got a mental illness, it's something that really does spring from the brain. All of the mental illnesses do, the seat of emotions is in the brain. It's actually throughout the body -- we have receptors for neurochemicals all throughout our bodies, but concentrated in the brain. We can see that when people are addicted, let's say, to alcohol or cocaine, or any of the other ingested drugs, their brains light up in particular ways, and change in particular ways that are very identifiable. So it is this brain research which is really revealing to us, it's the brain research that carries the greatest weight when it comes to making decisions about these disorders. China has proposed doing some of that brain scan research, and I don't know, I've actually heard a rumor that some of that brain scan research has been done for IAD, but I need to get my hands on it, because I haven't read it myself.

And certainly it's not in the mainstream at this point.

No, it's clearly not in the mainstream at this point, but when that does reach the mainstream, and when the powers that be get a hold of that research, and that research gets confirmed and done again, and it's irrefutable, that's what's really going to make the difference about calling a legitimate disorder.

Do you have a timeframe, a guess, in terms of how long that will be?

I really don't, I just don't know. I don't know if you're familiar with Kimberly Young, but Kimberly Young is a person who has also been a real pioneer in this field and she does do research, and she's pretty key to trying to acquire and gather together the research. I know that she's in touch with the committee that is making these decisions, and I know that she's trying to funnel them the research.

So you're starting the center with the goal of addressing this issue, but as we've just talked about it's not completely squared away. So how do you balance the mission of the center with that? How does that all affect the way you run the center?

The way we run the center? It really doesn't affect the way we do things. We know it's an addiction. If someone shows the signs and symptoms of addiction, and well it looks like a duck and walks like a duck and quacks like a duck it's a duck. So we know what we're dealing with, and whether or not the medical community kind of acknowledges it is kind of irrelevant to us, because we're the ones who are treating it. The only difference it makes is whether or not the insurance companies are going to be -- I think once it makes it into the DSM, the insurance companies will be forced to treat it, like they pay for treatment, just like they have to pay for treatment for drugs and alcohol.

So everyone that comes to your center now has to take care of themselves, there's no way that they can get support for that as a sickness?

Not through insurance. We do offer some scholarships -- right now, we want people to come, and we're willing to give some scholarships to people to make it as affordable to people as we can, who don't have the full cost available to them. But we look forward to the day when insurance is going to have to pay for it.

So let's just start off. You have one patient so far. In your mind -- obviously you can describe the one patient you have -- but in your mind, what kind of patient are you looking for? Are you looking for someone who has been through addiction programs before, or just someone who plays games 17 hours a day, or what kind of person do you expect coming to the center?

Well first of all we only take 18 and older. We anticipate that Ben, who is there now, is going to be pretty typical of the folks who come. He's 19, he's gamed for many years, but not addictively. While he was still in high school, he had a balanced life, but when he got off to college, he retreated for a variety of reasons, he was depressed and felt socially isolated and kind of retreated into the game and his life got completely out of control, and he started failing out. So I think that's going to be a fairly common story for the folks that we get.

There are tons and tons of people who play games, and obviously playing games isn't the only thing that will get you in there, but specifically someone who plays games and it affects their life, or how specifically? Is it depression, or how does it affect their life?

Nobody's going to want to come unless their lives are falling apart. What would be the motive, right? People are only going to come, and it's part of the definition of addiction, that whatever you're doing addictively, you can't control it, you can't moderate it. And it's having really negative impacts in your life, and in spite of those negative impacts, you find that you can't control your behavior. That's part of the definition of addiction. So the people who come are going to come because they're in a world of hurt as a result of their gaming, or their other Internet activities.

So it isn't so much of a diagnosis at all, it's more about people going "my life is in a place where it shouldn't be, and I think the reason is the Internet and the gaming," right?

Right. They're coming because their lives are falling apart and they need help. And we're there to help them.

Next thing then, when they walk in the door, what does it look like day to day in terms of the therapy that you're doing? You said it holds only about six people, and from the pictures it looks like a house in the woods somewhere? What's it like day to day as you're there?

It's a five acre parcel of land, it's quite beautiful, with open areas and wooded areas, and some very beautiful outbuildings where activities can take place, like there's a gorgeous treehouse which is good for a therapy session or yoga or meditation, or whatever. And there's two other outside buildings. There's a large garden, and the large house. The family, it's Cosette and her husband and their son, their quarters are upstairs, and then downstairs, there are two bedrooms with three beds in them each, and then a large living space. So anyone who's interested in coming comes first of all for two days just to check out the place and for us to check out them and see if it's a good match, because we don't want anybody to be there who doesn't want to be there. So nobody's there against their will, and so they come for two days, and if they feel ready and they want to do it then they can stay for 45 days. And during that time, they are going to be away from the Internet and all digital technologies, except occasionally some TV, and you know they can use the phones on a limited basis.

I did see him listening to iPods, so you can listen to iPods, but I assume no DSi, no Nintendo DS, right?

Yes, that's quite right. Because the idea is to get away from all of that, and begin reconnecting with the real world. It's 45 days so the brain has a chance to start normalizing. And during that time we can tailor the program, because there's never going to be more than six people, we can really tailor their treatment to their own individual interests and needs. The day is structured -- time to get up at 7, breakfast at 7:30, after breakfast there are chores like cleaning up, cleaning the house, just various chores and it's cooperative living, so everybody who's in the house shares those chores. Then physical exercise of some sort, tailored to the interest of the person. Ben loves to run, so he goes running, and we actually hired someone to run with him because he's a long distance runner. So they've been having a grand time running through the woods, and then after that, Ben has been meeting with Cosette to do a lot of work, basically coaching, and the coaching is to help him develop the skills that he's lacking to be successful in his adult life. So social skills, figuring out how to start to identify what he really wants to do with his life, and helping him develop plans around that. Talking about time managment, talking about stress management, these sorts of things. It's coaching and therapy both.

So it's not necessarily like you're talking specifically about games and saying "oh, you don't need to save Zelda," or whatever it is, it's helping the person to make sure they have the necessary skills to lead a life instead of play games all day.


And what's the goal when you're doing this -- it's a 45 day stay, at the end of it are you expecting them to never play a game again, or is it supposed to be game within moderation, or is that not a possibility at all. What's the goal at the very end of it, then?

They actually have to define that for themselves. It's not something that we're going to dictate to them. They have to figure it out by the end, how they're going to conduct themselves once they leave there, so that they don't fall back into addictive patterns. And we hope and our aim is to give them all of the tools that they need to be successful and avoid falling back in their addiction.

So in Ben's case, he knows that he really cannot go back to World of Warcraft, or any of the other MMO games that are on the Internet. He has to stay away from those, because they are -- his brain is going to be easily triggered to be releasing dopamine and get him hooked right back into that if he tries to play that game again, so he has to avoid it. He is at this point feeling like he can play casual games, so he will play casual games, or we'll see if he does, but he thinks he can, but he knows there's some things he has to stay away from, but equally important, he knows that there are things he needs to do, and those have to do with earning money, having adventures in the world, social and physical adventures, he's going to be going back to Colorado, there's hiking, skiing, snowboarding, all of these wonderful things. So he just wants to stay connected with the real world, so he can manage the Internet and gaming appropriately.

It's kind of interesting -- for alcoholics, for example, there's never a situation where you necessarily need to drink alcohol. It's not easy, obviously, for them to stay away from it once they start drinking, but there's never a time where like, for your job, you'll have to drink alcohol. But the Internet is almost necessary, in terms of a business environment, it's more intertwined in modern life.

It is more difficult because you can't just avoid it. It is more difficult and more challenging. And so we keep our fingers crossed, and hope he'll be able to do that, and he's going out into the world with a support system in place -- he's told friends that he needs their help, his parents, he'll stay in touch with Cosette to do some counseling long distance, he'll eventually find his own counselor and support group, he knows that he needs support and will not be isolated and try to do this without support.

Read on to part two of the interview, in which we talk about how the media has portrayed Internet addiction, and what games Dr. Cash plays and has played in the past.
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