Like most teenage boys, Cam Adair played computer games. He would play the games – Starcraft: Brood War, World of Warcraft –with his cousin, or to unwind after school or hockey practice.
"Then I started to experience a lot of bullying," the Canadian recalls. "And that bullying meant the gaming went from something that I was just playing after school to something that I was playing all day, every day."
Cam Adair is the founder of Game Quitters.
By his late teens, Adair was playing video games 16 hours a day. He dropped out of high school, never attended university, and was unemployed. At 19, he managed to briefly quit gaming, but he relapsed five months later, spending over two years gaming at an even greater intensity.
It was when Adair wrote a suicide note that he started seeing a counsellor. Instructed by his counsellor, he quit gaming cold turkey and started a retail job at H&M.
"Going to work was very challenging for me, initially. I was having panic attacks every day, throwing up in the shower trying to get ready to go."
Now 30, Adair has not gamed since. Instead, he has spent the past seven years creating Game Quitters, an online support community of over 50,000 people (including 2500 Australians).
Game Quitters provides online forums, educational resources and has operated camps in North America. Now, they have collaborated with The Edge clinic in Thailand for a clinical rehabilitation program for young men who have a problem with online gaming.
Once considered to be merely a consequence of depression, over the past five years, excessive online gaming has increasingly been viewed as a mental health problem.
In 2013, Internet Gaming Disorder was listed as a "condition for further study" in the DSM-5, the latest edition of the manual of mental disorders published by the American Psychiatric Association. Those with the disorder must meet five of nine criteria set out by the association, which include: a build-up of tolerance (needing to spend more time playing the games), failure to quit, using the games to relieve anxiety or guilt, lying to others about time spent playing the games, and withdrawal symptoms.
Professor Vasileios Stavropoulos, senior lecturer at Melbourne's Cairnmillar Institute and online gaming researcher, says it is important to note that the "further study" label does not mean the association is querying whether the disorder exists, but, rather, they are querying whether the disorder is being understood appropriately, given a current lack of research.
"It is a disorder, it is definitely a problem," he says. "Further research has been invited for it to be better described and addressed."
The Department of Health's Australian Child and Adolescent Survey of Mental Health and Wellbeing, released in 2015, found three per cent of young people aged 11-17 had what it described as a "problematic gaming habit" (although this categorisation was a lower bar than the DSM criteria). The habit was four times more likely to be observed in those who also had anxiety or depression, a trend observed in other studies.
Earlier this year, the World Health Organisation has also recognised "gaming disorder" in the 11th revision of its International Classification of Diseases.
Adair started Game Quitters after being frustrated by the lack of information and advice available to him when he was trying to stop gaming back in 2011.
"I looked online at the time, and the help I found it just wasn't helpful," he says. "It was advice like 'study more' or 'hang out with your friends'. But the reason why lots of guys game is that all of their friends are gamers."
John Logan, head counsellor at The Edge, says one of the biggest difference between gaming addiction and some other addictions treated at the centre is that the environment in which gaming occurs is unavoidable to most people who game.
"One of the problems we identified a long time ago was that, in today's world, you have to be able to use a computer, maybe even a smartphone," he says, adding that people in the age group treated by The Edge's program (men aged 18-24), are likely to want to re-enrol in university, or perform other activities which require internet use once their treatment is complete.
"We need to learn to regulate rather than be abstinent from."
The Edge's treatment begins with a six-week technology detox, where participants – alongside those being treated for other addictions at the facility – train for a triathlon and complete an overnight hike, while also taking part in group therapy and cognitive behavioural therapy sessions.
Then, technology is slowly reintroduced. In the first week, they receive two 30-minute sessions on a computer.
"They can only have one window open," Logan explains. "And they have to produce, two days before, what they are going to use the computer for. For example, email to contact family."
Treatment at The Edge is not cheap. Although Logan says the centre does not keep track of "success" rates for previous patients ("we try to stay in touch… but it's difficult to quantify"), and – having only started in July – the Game Quitters program is in its early stages, things do look promising.
"We've had three clients in the last two months, they are all now not gaming."
Overseas, a small number publicly-funded programs to tackle internet and online gaming addiction have emerged. In Germany, the STICA program provides 15 sessions of therapy. Spain also has state mental health treatment for the disorder.
Although he does not dispute that the therapy offered by The Edge is probably effective, Professor Stavropoulos laments that in Australia, as in the US (where the well known reSTART facility opened in 2014), treatment remains privately operated.
"As always happens with addictions, there is someone making profit when people are looking for treatment. Because if my son was addicted, I would do anything to fix them," he says.
"People are very vulnerable."
Adair's "worst behaviour" occurred while playing World of Warcraft, a multiplayer role-playing game which has amassed over 100 million registered accounts since its release in 2004.
"I think that's because it did a really good job of giving me a second life," he says. "You can also play all day without even knowing; there's no actual end point."
Online form of socialisation for those who lack functional relationships in real life is just one of the reasons why people become addicted to video games, Professor Stavropoulos says. In addition, the games allow the person to develop an alternate version of themselves.
"Their needs are prioritised [above] the needs of the player in real life," he says. "Because their persona needs to game, or participate in a raid, they end up not eating and not sleeping."
Then, there is the structure of the games: the systems of reward and challenge.
"On World of Warcraft for someone to reach level 60, they need to have spent 200 working hours. Everything is calculated."
In June, the Australian senate passed a motion to investigate "loot boxes" in computer games. Loot boxes randomised rewards which can be purchased by players within a game (Overwatch is a popular game which features loot boxes). A study published by Australian and US researchers in journal Nature this year found just less than half of a group of popular games analysed were psychologically similar to gambling.
"We need the companies who make these games to be regulated," Professor Stavropoulos says. "We know they have the data, and they know some gamers are playing more than 300 hours, consistently, a month… but Australia would have the same issue that all countries who have tried to regulate these companies have: the servers are based overseas."
Adair tells the story of a 15-year-old, whose mother referred him to Game Quitters after he stole two of her credit cards to attempt to pay for microtransactions within a computer game.
"He didn't even realise he was literally committing fraud," Adair says. "He was just trying to get something in the game."
Despite everything he knows about gaming, how it affects others and himself, Adair is reluctant to say he "hates" computer games.
"We're not against gaming, but that doesn't mean we aren't going to hold the gaming industry to account."
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