A very modern addiction
Sitting in his tidy flat drinking green tea, software engineer turned teacher Marc has forgotten how bad he felt after gaming for 24 hours straight. So he’s dug up a text he sent back in 2015 to his then girlfriend: “I had pain in my wrist. My head was pulsating, throbbing, I had intense cramp in my calf, and it felt like the veins in my eyes were exploding.”
In the depth of his addiction he wouldn’t eat, he switched off his phone, and did just enough to hold down his job. Only friends knocking on his door could stop him. “It was terrifying – why would I hurt myself like this?” he says. “I was lucid but I just couldn’t help myself.”
After visiting a pioneering Swiss clinic for internet use disorders, Marc has conquered his addiction to complex strategy games and other online habits. He’s highly intelligent, softly spoken and now spends his spare time playing chess – online – but no longer games with the same intensity. He carries around a paper envelope; inside is a card with coloured dots stuck on certain days of the week. This is a visual strategy he developed with the help of psychiatrist and psychotherapist Dr Sophia Achab, who runs the Geneva clinic for behavioural addictions. A dot signifies a positive action – meditation maybe, or a film with a friend, or a walk – at different times of the day.
“Often people like a concrete visual reward – like Marc’s dots – to show what they’ve achieved,” says Dr Achab. “It can be motivational.”
First opened in 2007, the clinic, hosted by the Geneva University Hospital, saw a 30 per cent rise in patients in 2019. Sometimes patients are children as young as nine or ten, and they see people in their 70s. Just 17 per cent of patients are female – it’s mostly young men, and their worried parents or partner, who come through the doors.
The last year and a half hasn’t helped online addicts. The Geneva-based behavioural addiction clinic that helped Marc has been busier than ever as patients tussle with family tensions, pandemic-induced anxiety and deep feelings of social isolation. Being stuck in limbo alongside their devices has been a severe test of self-control.
Dr Achab is a clinical expert for the World Health Organization (WHO) on addictive behaviours, from gambling, gaming and internet related disorders, as well as a public health adviser on digital wellbeing. Over the years she has tailored her practice and assembled a team of experts to deal solely with online problems, including problematic levels of online shopping.
Set off a busy Geneva street, with snowy peaks in the distance, clinicians here assess and provide tailor-made treatment which is mostly a mix of expert coaching and psychotherapy – though sometimes it’s just a practical steer and structure that some families need. “We have to be creative, everyone needs something different,” she says. “It’s not an easy step to ask for help – people don’t come to us because they are happy.”
Today Dr Achab is bracing herself for an 11-year-old whose parents are worried about his obsession with Fortnite, the first-person shooter game which has famously been developed with input from neuroscientists to be particularly engrossing. Early consultations can be draining as she tries to win the patient’s trust.
One 40-year-old client transforms when he begins to talk gaming, animated and eyes shining – but he’s proud of an app which shows how little time he’s spent today on certain games. He’s here because his wife and two daughters are desperate for him to control his habit, which has prevented him holding down a job. He began aged seven when his mum gave him a console. “In the end, [gaming] crashed my life,” he says. He’s fallen off the wagon but is regaining control – it can be a chronic condition.
In Dr Achab’s serene and airy office, next to a box of hankies, is a dedicated screen, where she has permission form the Geneva University Hospital to pull up the games, or gambling sites that engross her patients.
This helps her get to grips with what patients are going through – the little boy obsessed with Minecraft, or the Fortnite player. She knows her World of Warcraft from her Overwatch, and she’ll happily chat gaming strategies and technical details. “I had to be creative – it’s an emerging field and there was no blueprint for treatment,” she says. “I’m not against gaming – it can bring people a lot of pleasure.”
She’s not asking her patients for abstinence. “When patients realise I’m not their parent or spouse, and I’m not going to ban or set strict time limits, they begin to engage. My aim is for them to regain self-control and manage temptation – to reconnect with their life.”
Tall, elegant and immaculately dressed in black, she speaks softly during consultations, with pithy interjections, but great compassion. She knows how hard her patients struggle with cravings and the mechanism of addiction. “They want that immediate, intense dopamine release, that immediate trigger of the reward system in the brain.”
Not all who come through her doors are addicts – part of her job is assessing the depth of a problem and what’s behind it. “But please, please don’t question patients whether internet addiction exists,” she says. “For many people, it’s real and painful. They are suffering.”
Dr Achab is referring to the controversial decision by the WHO to name gaming disorder as a disease. She’s part of an international group of doctors, scientists and policy makers who annually discuss provision and treatment. She’s also advised colleagues around the world in setting up similar centres.
“If you don’t name a disorder, health services can’t train people to treat it – it’s an emerging field and there’s so much we don’t know,” she says. “We need to understand it from a patient’s point of view.”
In another room sits Jerome, 55, who just a few years ago was a bank manager but whose alcohol and gaming problems have led him to lose his job. “He lost a lot of money, spending it online to try to be the best, to be the boss he could no longer be at work,” says Ana Diez, a psychiatric nurse and online addiction specialist who is part of Dr Achab’s team. She’s coaching him to find new purpose now his marriage and professional life have collapsed, and he’s planning to head out travelling in a camper van. When he first came, he was having suicidal thoughts. With help, he’s conquered his compulsive gaming – next step will be the alcohol. The mood is light, jovial and optimistic. “You have to take patients on a winding path towards the goal,” says Ms Diez.
How do they do it? With skilled assessment and bespoke treatment.
Dr Achab recalls a 15-year-old girl who compulsively sought sexual encounters via the internet. She was adopted – her behaviour, Dr Achab determined, stemmed from her feelings of guilt at meeting her birth mother, who was a sex worker. Addressing this eventually helped solved the issue. Another child played the “strong man” at home, but feared his mother would die after acute surgery. He was transgressing family-set gaming limits. “He felt the need for escapism, he couldn’t share his fears,” she says.
She has a host of stories, many revealing complex motivations behind compulsive behaviour – carefully unpicked during therapy. She tries to explain to some parents how limits they set might be overly strict; an hour, for example, is not long enough to play some games properly.
“Our aim is to help people reconnect to themselves, their lives,” Dr Achab says. “The more mindful of what you are doing, the less you will be automatically hooked. We want to ‘unstick’ people from their impulses.”
Patients are set small tasks at first, such as lengthening the time between experiencing an impulse and satisfying it. This helps patients realise that the craving does eventually pass. Even children can learn to set their own limits with gentle guidance.
Is there anyone she can’t treat? “Yes, sometimes I don’t have answers.” Once or twice a year, she’ll hear of extreme cases – usually a young man who doesn’t leave home, has stopped communicating, eating or looking after himself – a phenomenon the Japanese call Hikikomori. “You can get bed sores, malnutrition, dehydration, blood clots – all sorts of complications,” she says. “But if they’re not willing to open the door, there’s little we can do.”
Difficult and numerous are the teenagers who’ve reached 15 or 16 and have never experienced any guidance or parental limits. “And suddenly parents want to restrict them – and that doesn’t work, that often results in violence,” she says.
Treating these cases requires motivation and empowerment. Invariably teenagers do want to control their habits but don’t know how, and it takes a neutral person to intervene. Internet use becomes a problem in the presence of three specific elements: addictive property of the product (a game which triggers a feeling of danger, sexuality or reward for instance); a vulnerable person; the environment – which could be conflict, work difficulties, or even the accessibility of a product.
As for her own online life, Dr Achab switches her phone off in the evenings, uses social media for practical purposes and sees people in person if she can. She shows how to turn a phone screen grey – so the inviting colours of Facebook, or Call of Duty don’t sparkle and trigger a kneejerk reaction.
The internet, she says, is an utterly immersive environment – when we’re deep in emails, or on social media there’s an intensity. “It’s normal to forget the outside world. But I deeply believe you can empower people to take control of their lives – I start from the very beginning.”