Dr. Hilarie Cash, Ph.D., LMHC

Contact Info
reSTART Internet Addiction Recovery Program
PO Box 490 .
Fall City, WA 98024
United States
Phone Number: 
(800) 682-6934

Below is an interview with Dr. Cash and the Polish gaming website MMOZin.

reSTART clinic in Seattle takes aim at helping addicted gamers

Internet addictions, and more specifically MMOG addiction, have been hot button topics for several years now. From prime time news stories on "investigative journalism" shows to our own articles here at Ten Ton Hammer, the problem has been examined from nearly every angle. With the growing number of gamers and the increased visibility of this type of addiction it seems a foregone conclusion that we would begin to see specialty clinics pop up to treat folks who are struggling to control their play time.

Polish gaming website MMOZin has tracked down just such a clinic, reSTART Internet Addiction Recovery Program, and were able to sit down and speak to its director, Dr. Hilarie Cash. We have partnered with them to bring an English language version of the story to you, thanks to MMOZin writers"Achilles" and "Kroliczek"for this fascinating interview.


 MMOZin: Hello. Can you tell us a few words about yourself and your role in the reSTART clinic?

Dr. Hilarie Cash: Hello. I am the co-founder of the clinic and we started it just this summer. I have been developing my work with internet addicts since 1994 when I met my first video game addict. 11 years ago I co-founded an outpatient clinic called Internet/Computer Addiction Services and last year I co-authored a book called Video Games and Your Kids: How Parents Stay in Control.

MMOZin: So how did you meet your first game addict?

Dr Cash: He came to my office when I first moved to the Seattle area. He was one of my early clients and he was depressed; his marriage was falling apart. As we worked together it became clear that he was addicted to an early Dungeons & Dragons game--text only, no graphics. But he was classically addicted. He had lost 2 jobs because he could not stop playing and he eventually lost his marriage as well.

 MMOZin: Can you tell us something about the clinic itself? Where it's located? How many patients you have now and how many a year? How long does the therapy last?

Dr Cash: Sure. The clinic started just at the end of July 2009, so we are relatively new. We have had four clients: three young men and a woman in her thirties. They have all finished and we are on a break until the New Year. It's located in Redmond, Washington which is the home of Microsoft. When people come, they come for 45 days. It is only for adults; patients must be 18 or older. When they first come, they come for a minimum 2 days to be interviewed and to interview us, because we don't want anyone there who doesn't want to be there. So if they decide they want to be there then they stay for 45 days or longer if they choose. During that time they don't have access to the internet. The idea is that it takes at least 30 days for the brain to make some adjustments it needs to make to get over this addiction, so the brain can begin to rewire back to normal. During that time we are helping them look at why they got addicted, what motivated their addiction and we're assessing to see what skills they are lacking so they can be successful in their adult lives. We try to make a good start at helping to build those skills. It is a multi-faceted approach. They live on a regular, daily routine of waking up at a normal hour, having breakfast, cleaning up, then after breakfast doing chores in the house and on the property with the animals and in the garden. After that they have psychotherapy and education related to their addiction and the skills they need to develop. Then it's lunch, and after it is group psychotherapy and life skills coaching. Then it is time for them to work with Cossetes husband, Gary, who is in construction. They help him with building projects on the property.

MMOZin: The girl also?

Dr Cash: No, she had art projects. She didn't want to work outside so she was able to do work on them - she's an artist. In the evening people come together and there are responsibilities that are shared for preparing the evening meal--cooking planning, all of that. There's also meditation training and one twelve-step meeting during the day on Monday and another in the evening on Friday. Then it's free time for the rest of the evening.

The addicts, and in particular most of our clients, will be like the young men we've seen so far, who were 18, 19, and 25. They will be behind in social skills, because their social lives have been lived online and not in real life. So, the idea of all these structured activities is to help them develop social skills and begin to address the lack of just simple daily skills that
they need to develop if they're going to take care of themselves independently as adults--taking care of their personal hygiene, learning to cook, clean up their physical space and just being adults in the real world. We find that they generally are not good at that. And then, we start to look at psychological factors they need. Sometimes they're on medication for depression, anxiety, or ADD.

MMOZin: You have a doctor there? 

Dr Cash: We work with a doctor in Redmond that they can visit. They sometimes choose to go off medication, or they can stay on medication, or they might need medication for the first time. What I have certainly found over the years is that depression and anxiety and even Attention Deficit Disorder are conditions that are sometimes brought on by some spending too much time online and playing video games. When they get a break from that and begin to engage with life and begin to develop the skills to feel successful in life, the depression and anxiety begin to lift and go away without the medication. 


 MMOZin: Do you think that  the addicted person can help himself or herself or is it that kind of addiction that really needs  help from specialists?

Dr Cash: I think it depends. There are people who are capable of recognizing that they seem to have an addiction and they pull back and cut down the amount of time they're spending online or take a fast and stay away from it for a while. There are definitely people like that, and many can do that in fact, but there are some who can't, who are so deep into their addiction they have lost all the control and seem powerless and those people need to seek professional help.

I want to say one more thing: if the person is young enough and living at home, the problem can usually be handled pretty easily once the parents understand how to set appropriate limits and are effective in that. Once parents can structure their lives in a way to regain control over the computer and that technology, and if the kid is young enough that they will listen to parents even if they are mad, it works very well. If I have parents of younger teenagers I only work with the parents; I don't worry about working with the kids usually.

MMOZin: But these teenagers are still minors? Or are they adults?

Dr Cash: When I work with a family I'm working with minors. When they come to me at reSTART we're working with adults.

MMOZin: What's the average age of an addicted player?

Dr Cash: Well, I'm not sure. The people who come, that I see, are almost always between the ages 18 and 30. There are certainly people older that are addicted as well.

MMOZin: Okay, as I understand it there are more boys addicted than girls usually?

Dr Cash: I think that if you take the internet as a whole and include social networking and shopping and other activities it's pretty even in terms of addiction. When it comes to the MMOs it's far more boys than girls.

MMOZin: When we are talking about MMOs or other games, but I think MMOs mostly, are there addicted players identifying themselves with their virtual identities when they come to you, or is it an addiction like spending too much time playing games?

Dr Cash: That is an interesting question. I'm not sure what the answer is. I think when players play and create an avatar they do identify very strongly with their avatars and they certainly often like who they are more in the game than how they are in the real world. They prefer the way they are in the games over their real world experiences. So I think there is a very very strong identification with that. As a therapist my challenge is getting the people who are helping players understand what it is in the game that they like so much about themselves and help them find ways to bring that forward into real world.

MMOZin: Is there any time limit that says you've played too much?

Dr Cash: You're not going to like my answer. There is some research which shows a correlation between the amount of time and the signs and symptoms of addiction. This is early research so I don't know if it is still true. But early research done in the 90s shows that people who spend more than 2h a day online in entertainment - you know, not work, but online socializing and entertainment - then they started showing signs and symptoms of addiction. As a rule of thumb,  people ask "What should the time limit be?" I will always say "Don't spend more than 2h if you want to be sure you don't want to be addicted".

MMOZin: Yeah, but it can be hard sometimes, really. Two hours is very little time, and it flies by fasst.  Anyone could become addicted.

Dr Cash: Remember that part of the definition of addiction is that all addictions have some things in common. It means, at least at the beginning, you get a high, because you're enjoying it so much. Then the brain makes adjustments, because it's getting too many of the neurochemicals and withdraws the receptors to pick those neurochemicals out --that's called tolerance. If you spend too much online or in video games, your brain is making that adjustment. And then, if you're not spending time online, you're at risk of going into withdrawal, when you're unhappy, discontented and uncomfortable because you're not engaged in that activity.

Once stuff begins to happen, once you're body develops tolerance, then you need more time or something new in order to achieve the pleasure you're seeking. Then you develop tolerance to that new level. That's how it works. Because you're hooked into that, if you start to feel out of control, that's when you start engaging in being on the internet and playing video games even though there are now, and will continue to be, negative consequences. Those consequences could be alienation from your friends and family, or physical health problems because you aren't getting enough sleep, or problems with work or school and so forth. Those are the elements that need to be there for us to call something an addiction.

MMOZin: What do you think about the psychologist opinion that games are evil and teaching players to be aggressive? Do you think that the games are as bad as psychologists say or do they have any positive aspects to themselves? How do you see that being a therapist in game addiction?

Dr Cash: I think most games are fine in moderation. The key is moderation. The whole subject of aggression in games is still very controversial. I think it's not good for children to be exposed to a lot of violence, whether it's television violence, movie violence or video game violence. I don't think it's good for the kids. I do think it begins to desensitize them. The parents need to be selective about what video games they allow their children to play. Once you're an adult even playing the violent video games is fine in moderation. The lack of moderation is problematic. I think there are lots of video games which can have very positive benefits in peoples lives, but it must be viewed as moderate entertainment and not viewed as "this is my new world and I'm going to leave the real world behind."


 MMOZin: What do you think about the methods used in Chinese clinics?

 Dr Cash: Methods of beating, electric shock and so forth are horror stories; those are terrible. I visited a clinic in Bei Jing and that is not one of the clinics that have been reported as having any terrible things happening. It was fascinating to go there, because it was a combination of a military boot camp--a lot of very rigorous, vigorous physical activity, wearing a uniform, learning to handle weapons--it was like military training. It was this, but also Western-style psychotherapy. They had sound trade play therapy, music therapy, group therapy, individual talk therapy, and anger release therapy. Those are good techniques.

I came away from my tour of Bei Jing facility with a basically positive outlook on it, although I would love to spend a month or so just really observing what it was like. Still, my impression was fairly positive. The clinic is run by doctor Tau who is a very smart, capable and caring man. I think he's created a fairly good Chinese-style program, very different from our own American style. The other places may be absolutely awful. It's awful if anybody is being beaten, electric shocked and all of that.

 MMOZin: Do you think that different nations can have a different method for addiction therapy?

 Dr Cash: I think it's inevitable that different cultures are going to produce different solutions. I can tell you that I have been contacted by people in China who are very interested in trying to model what we are doing over there. So they're interested in learning a gentler approach. We'll see what comes about.

MMOZin: Are there any statistics saying how many addicted players there are in US or China? Are there any statistics at all?

 Dr Cash: Well, in the US the most recent research is suggesting that addicted video game players range of about 8.5% overall of kids between the age of 8 and 18; they meet the criteria for addiction.

 MMOZin: And adults?

Dr Cash: For adults it's actually very similar. It's interesting though. Nick Yee [author of the Deadalus Project website -Ed.] spent his young career--he's pretty young, about 30--researching inside MMOs. I haven't read his most recent research, but I knew earlier it suggested that among MMO players the rates of addiction were probably pretty much higher.


 MMOZin: Could you tell us any kind of special case of addicted player? What was the most unusual player?

Dr Cash: The most unusual case? I'll give you two. One is a 25 year old man whose wife came in with him. He had been a star in high school and earned a scholarship into a very exclusive university. He was an athlete, very socially popular and loved to play games as well, but it wasn't a problem. His life was good and he played games appropriately.

When he went off to the university he got very anxious that he won't be good enough to succeed. So, instead of working harder to be competitive, he escaped his anxiety by playing MMOs and he was eventually kicked out. He married his high school sweetheart and moved to the Seattle area where he got a job in the computer industry. The game he had gotten so addicted to was Everquest. He made a promise to his wife that he will never play Everquest again. For one year he didn't play it.

 MMOZin: But he played other MMOs?

Dr Cash: No, he stopped playing MMOs. Things went all right. After a year he decided it was ok, he could play again. He had made the promise to his wife that he wouldn't and so he deceived her and started playing in secret. He would go to bed with her and then when she was asleep he'd get up and play the game. In the morning he would get up with her and pretend he was getting to go to work, she would leave for work, but he stayed and played the game. Of course he got fired from his job, but he didn't tell her. He just kept up the charade of pretending that he was working. He completely became addicted. He paid their bills with credit cards and it was all a big lie. Eventually he became so depressed he became suicidal. He confessed to everything to his wife who brought him to me. There's an example.

 MMOZin: Did it turn out ok in the end?

Dr Cash: Yes. It was great. He was easy to work with, because he had lived his life to adulthood as a very healthy young man. So, he knew what it felt like to be healthy. It was easy, really. In the end, he knew he had to stay away from video games entirely, like an alcoholic has to stay away from alcohol. He just knew that about himself. Once he made that commitment he started doing some twelve step work and as far as I know he's fine. They moved away and I lost touch with them, but as far as I know they're fine.

Another case is a young man from this area who, again, had a pretty normal life up until he went off to college. He played video games, but in moderation. He was a good student, he ran cross country, and he had friends and a social life when he went off to college.

What was very significant about him is that, although he had friends, he was socially shy and he hated his father who was abusive. When he went to college he met other gamers in the dorm and he just squeaked by passing the first term. But, thereafter he would sign up for courses and then he would withdraw by the withdrawal deadline. He lied to his parents that he was still in college, taking all the college courses, creating a fake transcript which he would show them to prove that he was doing well. For 3 years he kept up that deceit and his parents paid for his university. He didn't have anything to show for it. He eventually was kicked out and was suicidally depressed.

He was much more difficult to work with. He has been gaming at this level at that time for about 5 years. He was very far behind in his social skills. He was really scared to be out in the world--he had become agoraphobic, didn't want to leave the safety of his room. So in the end he was unwilling to end his gaming entirely. I couldn't make him do it. It was a very long, slow process of working with him.

MMOZin: How long did it take?

Dr Cash: I worked with him on a regular basis for 2 years. The best thing that happened to him was that he did eventually have to work because he ran out of money. Then he got a horrible job, so he wanted a better job and he got that. Then he didn't like that job and he realized that he needed his university degree. That motivated him to return to university. They made him to write a whole essay about what happened to him and why they should take a chance on him one more time. He wrote that, they accepted him back, and he's a graduate. His life is slowly improving, but he's now 26 and he doesn't date. He's way behind his peers socially.

MMOZin: These were really unusual examples, I think. They were in a very difficult position. Usually it isn't so difficult, right? Addiction is more moderate, right?

Dr Cash:  The young who have come to us at the reSTART Program all have similar stories. What I have found is that if somebody can come for treatment when they are young enough and I can work with the parents then treatment is easy. If they are older, in their twenties and mature enough to realize what a fiasco they have created for themselves, and they're ready to work and not in denial about their trouble, then that's easy as well. What is difficult is when they are older teenagers or young adults who do not yet admit they have a severe problem. Then they're harder to reach. When somebody is still too strongly in denial, they haven't experienced enough pain to be willing to get help.


MMOZin: Is there any difference between women and men when they are addicted and any difference in therapy?

Dr Cash: Well, therapy always has to be adjusted to each individual. In general, the women that I worked over the years have been far fewer in number and their issues have often been centered on falling in love with people in the game and developing a whole fantasy life around relationships. It's different from what motivates a lot of men.

 MMOZin: That's an interesting point of view.

 Dr Cash: One of the games that are very popular with women is Second Life. It can be a place to live out fantasies and relationships.

MMOZin: There was a psychologist named John Carlton, who said that addiction is a feature of personality. Are the persons who come to your clinic easily addicted to other factors, for example smoking or something else before coming to your clinic?

Dr Cash: No. I do think once a person develops an addiction then they're more vulnerable to another addiction. So I think they're often all called addictions and it might be to drugs and the internet, smoking and the internet, or whatever. Most of the people I have worked with over the years haven't been addicted to anything except the internet.

 MMOZin: Do you know if after the therapy they became addicted to something else?

 Dr Cash: Not that I know of, except that I do a lot of work in that program in our clinic called Internet/Computer Addiction Services inpatient--we work with a lot of sex addicts and their partners. Those sex addicts are, for the most part, very vulnerable once they give up their addiction to pornography or sexual acting out. They have to be very careful to not become addicted to something else.

MMOZin: Does the Ministry of Health give any refunds for the therapy for addicted players?

Dr Cash: Not at our inpatient setting, but we work with the Diagnostic Statistic Manual [DSM-IV] which has categories of psychological disorders and there's a category called "Impulse Control Disorder". If somebody, like a video game addict, comes to visit me at my office I can bill the insurance for that.

MMOZin: Is there any scientific name for the game addiction or was that "Impulse Control Disorder" the name for the game addiction?

Dr Cash:  No, it is called "Impulse Control Disorder, not otherwise specified." So it is a general category that's not specific. In the next version of the manual, which will be coming out in two more years, there's going to be a large category for non-substance-use addictions. We know gambling will be there, because there's a lot of research on gambling. We're hoping that they will also include video game addiction and perhaps sex addiction, but we don't know yet what they will decide to include. It's all a matter of evidence, good research, and it comes along slowly

MMOZin: Will it change anything if they include it in?

Dr Cash: I think it will be huge, because then the insurance companies that pay for health insurance will have to cover it in the same way as they cover chemical dependency, drugs and alcohol

And it will be huge in terms of people in my profession. So many people in my profession don't take this as a serious problem. They don't like to think of this as an addiction and don't know much about addiction in the first place. So if it gets into DSM that will change the landscape a lot. So I hope it happens.

 MMOZin: It would be great. Is there any test or quiz that you could give to our readers that they could do and check if they have any problems with gaming.

Dr Cash: Yes. Direct our readers to our website: netaddictionrecovery.com . There is a signs and symptoms checklist that they can go over and we tell them how to score that. It's not a definitive, but it certainly will give them an idea of whether they have a problem or not. 

 MMOZin: Do you play games? What kind?

 Dr Cash: No. But I have a son who is 19 and he enjoyed video games and so I tried to play some video games with him, but I was so bad it was no fun. Oh, there were some Mario games and... I don't remember the name... Soccer, you know, FIFA.

MMOZin: Thank you very much for explaining everything to us. It was a very interesting talk. I think me and our readers will have a different view on gaming or at least think in different light about it. That was really educational. Thanks again.

 Once again we would like to thank the folks over at MMOZin for bringing us this interview, if you would like to learn more about the clinic or need help with internet addiction you can visit reSTART's website here.



Liz Woolley