 to Virtual Abilities 2019 Mental Health Symposium. My name is Katzai Tenen. I'm 71, semi-retired, and 11 years old in SL as of yesterday. In SL, I can dance, create, work, and play in ways I can't do in real life. Am I addicted? I don't think so. But I'll listen to our next presenter, Dr. Tony Van Roo, Roy, and find out. Dr. Van Roy's talk is titled Gaming, Problem Gaming, and Gaming Addiction in the Netherlands, an introduction. Dr. Van Roy is project leader for gaming, gambling, and media literacy in the Trimbos Institute, the Netherlands Institute of Mental Health and Addiction in Utrecht. His research interests are in development of serious games, game-based learning, and mental illness assessment. In this presentation, Dr. Van Roy will introduce concepts that can help us understand gaming addiction more easily. He promotes the responsible and healthy use of video games. He will use the situation in the Netherlands as an example to explore concepts of healthy and unhealthy gaming. I remind you to turn off your mics and refrain from questions or comments until the end of the presentation. So as time is short, please join me in welcoming Dr. Van Roy to the podium. Thank you. All right. Let's see if I can figure this out. Yeah, there we go. So I'm assuming I can be understood with the voice, otherwise just insert some questions and I can see if I can fix it, but I'm sure it's fine. So my name is Tony and I've been working on gaming addiction, the subject of gaming addiction for I guess the majority of my career now, starting with survey research among Dutch high school students and ending up now in a position where we do prevention efforts in the Netherlands for gaming problems. I'll not exactly be following my teleprompter slides, but they should be addressing the core of my message. So that said, it's pretty obvious to people and to me as well that there are a lot of concerns about how much screen time is healthy. And this is actually, you see this quite easily if you go into Google and you actually go into the function that adds text to your questions. And there you can see that people are very much concerned about how much screen time is enough, how much gaming time is enough. And even if you look for the word addiction, then it supplements gaming, internet, mobile phone use quite often in addition to what you would expect, like for example alcohol or heroin. So there's definitely something going on in the public perception. There's also something going on in my personal experience with the subject because it's not exactly a secret that I've always been a gamer from a young age. But it was only in 2005 with the introduction of World of Warcraft that I actually started meeting people in games more extensively. And I often use this example of a guy I knew in Warcraft called Stealth. He was very successful in the game and he had a large amount of equipment. He was running his own guild. He was basically achieving a lot in the game. It was actually quite surprising to me that one day he suddenly decided to quit the game. He wrote a dramatic post on the forum, he announced he would quit the game. That would be the end of it because as a perfectionistic person, he focused too much on World of Warcraft and it basically to the detriment of his study performance. So he decided to quit. He tried to anyway because he was back a week later and the last time I checked a few years later he was still playing extensively. So there was one of the people I met in Warcraft that really made me think about what's going on with some people and excessive play. Which is what got me started in my PhD research. Alright so throughout this fairly brief presentation I will introduce two concepts that I like to use to understand gaming problems. They are basically the fish trap, a very Dutch device to collect fish. And it is a device where the further the fish swims into the trap, the harder it is to get out again because there's a very small entrance and you can only basically... So it's hard to swim back but it's easy to swim forward because the hole to the next area is relatively speaking a lot. Secondly I like to use the onion as an example because I think in understanding gaming addiction it's really helpful to go through a number of layers of understanding. And the first one for me is basically media. We're all exposed to media portrayals of games and very often they're heavily polarized. So it's either games are going to save the world by enabling people to become healthy or solving certain problems or vice versa. There's a large debate about aggression and very often about addiction. So it's good to understand that by definition the media is portraying fairly polarized images of gaming, specifically gaming addiction as well. And they tend to blame a single actor. So it's either the companies that are creating products that are abusive or it's the players who should basically have more self-control or it is the parents who are basically responsible for not paying enough attention to their child and using the game as a digital nanny for all sorts. So very often it's reduced to an oversimplified situation where in reality I think they're all interacting and they're all quite relevant. Now if we look cross-cultureally, there's a fairly big difference between countries. And the specific best example of that is the Asian countries. And in this case, we see an image from China where children are basically after gaming too much are reeducated in military style reeducation camps. Now I'm fairly sure that these days they're less prevalent than they used to be. But there's been some controversy about the treatment of people in these camps, including forced medication and forced electroshocks. So the concept of gaming addiction in the hands of certain governments can really have detrimental consequences for persons for sure. It's not something to be taken lightly, especially at a worldwide level. So the second layer of I guess disclosure is can you trust me up to a point I guess. So I work at the Trimbos Institute, which is a government-sponsored institute, which does basically health promotion. We tend to work on reducing tobacco use in society, reducing alcohol use. And my specific thing is not necessarily to reduce game use, but definitely to understand problematic gaming better and gambling as well. See that in the next slide is some brief screenshots of some of the type of projects we do. They're very often they're Dutch language, so they won't be too helpful, but I do have some English texts as well, if you're interested. Feel free to contact me. Basically, these efforts focus in two areas, both implementation and information for the general public, so prevention projects, and secondly, more fundamental research. And we have done both and I am currently doing both. So for example, I might be right now developing a new screening instrument for assessing gaming problems. Second disclosure, I'm also a gamer, not a secret at this point. Here I am in the middle, very proud of this. This we defeated Nevarian, a boss in Blackwing Blair in World of Warcraft. This is the group I was playing with. I think at this point it was 40 people. I often show this to the general audiences. To basically address the question that people are achieving real things in these games. Because if people are not informed about games, they tend to think that no accomplishments are going on, it's just a waste of time, it happens. Those thoughts are somewhat prevalent. I think that we defeated this dragon was a real performance. It was definitely difficult and there was a large release after we defeated it. Everybody was happy and as often happens, try to defeat the dragon. And then one person's mom gets angry and he has to leave the room and then you're screwed to 39 people. So many things are going on. It's complicated. But as we're all in second life, I guess that's already clear to some of you. So moving on to the actual content and the Dutch situation. I like to employ for thinking about these subjects, basically the fish strap model and I'll show a picture of it. The first, I guess not even pictured here, is the first level of technology used, which is basically, it's beneficial. You work all day or you do other things and then you decide to relax a little with a video game. And it's, I guess objectively demonstrable as well, that it's beneficial. You get richer, you get additional social contacts, you do something, it takes your mind of things, it's taxing. It's basically play as part of your healthy human functioning. However, these days, some people have some mild feelings of discontent about their, either their Facebook use or their gaming. You might ask them, are you addicted to mobile phones? Are you addicted to Facebook? Are you addicted to your games? And they might say yes. Actually, a fairly large percentage of people in research say yes. Might be up to 20 or 30% even, even if you ask them about social media use. And I would label that, obviously these people are not patients, but I would label that as, yeah, what I say here, mild feelings of discontent, self-reported. There's something going on. This is another example of this line of reasoning. This is Belgian research where we see fairly high percentages here in the, ooh, it's like 20% of people that self-report, that they have trouble getting away from Facebook. They might feel they should be doing less, but they're unable to do it. That's fairly high percentages of people that self-report this. So interesting, but from my perspective, the first step in understanding this, and it might also be an indication of something that's not even addiction, but just of other issues with the social media and how they treat people. Now, the second one, which is more directly related to excessive use and problems, it is what I would say is I define as problematic internet or gaming behavior. Or if you will, problematic social media or problematic mobile phone. It doesn't really matter too much, although we see it most often for gaming. And this includes basically all of the research that's out there. It involves survey research where people, researchers often go into schools, go into universities or go into society. And they ask people about their gaming behavior and they say, they might say, do you have problems controlling yourself? Have you tried to reduce your use and have been unsuccessful in it? Does video gaming create problems with your homework or with your health? And very often in survey research, a significant proportion of people say yes to this, even if you add up all the questions. And generally arrive at like, between 1 and 5% of people will be saying, will be indicating a number of problems in relationship to their gaming or internet. In the media portrayal of this, this very often this is referred to as addiction. So you might have a newspaper report in the Netherlands that says, 10% of Dutch adolescents are addicted to games. While I personally will see that in a bit, I personally prefer to reserve the term addiction or disorder for people that are seeing a therapist and are not in school anymore, filling out surveys. This is an example of an instrument that we might use. And it involves some core components that cover a loss of control over the behavior, problems and interference with real life. And then very much like what the researchers do with gambling, there are some associated phenomena. For example, preoccupation with the behavior, people go gaming to modify their own moods, so they might try to escape a bad mood instead of solving the underlying problems. And if they quit, they might experience at least psychological withdrawal phenomena. Now, some actual empirical data from the Netherlands recently. I summarized the HBASC, which is a fairly big study on high school age students. And here it's unfortunately the text in the slide is somewhat touch, but in the bottom it shows the percentage of real players that are for scoring high on risky or problematic gaming comes out among the boys to 7% of the players. If we look at the red area, which is the group within the group, which is experiencing both a mental problem and a physical problem. So that might be obesity or being too light or not brushing their teeth enough or not skipping breakfast a bunch of times. So that would be the physical things. Mental would be slightly more rigorous indicators of, for example, depression or not feeling so well using the sdq scale. So we see that in this group, although in absolute terms, it's a small group. Within this group, they score five times more likely to have these issues. So this is definitely a problematic group. They are gaming too much and they score high on these issues. And then you get a chicken or eggs question, of course, because if you're not feeling so well and it's very tempting to sit at home and have to fill your time with something. So you might end up games or watching Netflix. But unfortunate thing with games is that I guess also the fortunate thing is that they relieve loneliness. They make you feel like you accomplish something, which is great. Up until the point that it becomes a central part in your identity and central part in your life, that can really cause over the long run some problems with your development, especially if you're. So very interesting, but not necessarily patients related per se. Although a bunch of these people might escalate to be patients. So this is where I reserve the last category in thinking and that would be the last part of the fish trap as well. People that are a disordered or have a gaming addiction. This is not a large group. They do exist and very often they have comorbid issues. It's actually fairly rare to find a gamer that is just gaming and has to see a clinician. Very often there's depression going on or people in the autism spectrum and are not coping one with life in other ways. So there's problems in the family. It's very rarely an isolated issue, although it does happen. If you look at the numbers in the Netherlands, unfortunately we only have official measurement up to 2015. Nationally speaking it's a small issue, like less of a percent within the addiction care treatment numbers for addiction. So alcohol at the national level for example is a much bigger problem. However, more recently the measurements on the national level have stopped but with the reports from the Dutch youth clinics we hear that gaming problems are now in the youth clinics the second biggest problem in some places after cannabis. So increasingly young people are coming into the clinics with their parents with severe problems in school in relation to the gaming behavior and in some cases in a significant number of cases I suspect even there's it's just panic among the parents about the gaming behavior because you know they'd rather that child was playing soccer than trying to become a professional in fortnight but in some cases there's actually something going on and there's a large the therapists feel they have a large need for a better grip on this problem. Now looking at the diagnostic criteria we have in 2013 the DSM5 manual introduced a tentative preliminary category for gaming disorder which is I guess grouped in some ways but I'm mainly negative about it because it's in practice people are only using the nine criteria copied based from the nine criteria that DSM mentioned and they also made up a cutoff score for the skill which is basically five out of nine or higher you score positive on gaming disorder but the unfortunate thing is is that there's only really two negative items in this list so and many of them sorry about the Dutch but many of them are actually did they deal with preoccupation for example that's the first you're thinking about games a lot from my perspective that's not an ideal question secondly there's a number of debatable criteria in there so for example withdrawal symptoms non-physical that makes a lot of sense with substances with gaming that's so I guess the third one is even more debatable like for example tolerance. Tolerance makes a lot of sense if you're drinking because your body builds up a resistance but in practice people have started drafting survey instruments that cover gaming and say you need to buy better computers all the time to feel equally equally good about your gaming and I don't think that paints a very realistic picture of how people participate in World of Warcraft they tend to buy a new computer when their old one burns out I think so there's some unfortunate choices in there but it was however I guess a starting point and I guess the main the main risk with the DSM-5 approach is that people they go blind to the things that are not in there so they might end up ignoring the nuances that really make gaming different from for example a substance use problem or even from a gambling problem and we now have a new effort from the World Health Organization which also announced that they're drafting a gaming disorder which was actually some substantial debate about it but they seem to be pushing forward with it. The fortunate thing is that it really places unlike the DSM-5 in its implementation anyways it really places functional impairment centrally so the behavior pattern of gaming has to be of sufficient severity to result in significant personal impairment in personal family, social, educational, occupational or other important areas of functioning that's great because that will really help us in dealing with people that might be prejudgmental about gaming or have a limited understanding you can say well it's not been a year and the functional impairment might not be big enough I guess it would have been nice if they made an exception for example for professional esports but it's a starting point but again like with the DSM-5 you have to ask if if we might be missing some central aspects of gaming by reducing the gaming disorder to just this very central and obviously important criteria. If we look at the history of for example gambling disorder we see actually a similar pattern where people historically gambling in the DSM-3 was phrased as a loss of control over gambling leading to significant problems pretty much exactly what we have now for gaming disorder but later on we added a criteria like chasing your losses which is very gambling specific you try to win back your money. Lying is also a very central criteria in gambling because you lose your money and then you start hiding things from family and people around you because you're very much ashamed of your consequences of your secret behavior so it might well be that this is a starting point for a more nuanced understanding in the future I hope it is. Like I said there was substantial debate about this disorder I participated in this debate as well but I'm personally at the point now where I say we have to deal with it. I guess it's helpful in the sense that we now can address we have a clear universal label worldwide to deal with the patients better but it's definitely good to be critical. Now some practical notes we see actually unfortunately mainly due to the debate I guess but it might also be a historical trend that always happens industry is not very responsive in public with this issue and what we see mainly is that some initial attempts from in this case telecom providers and Dutch game addiction game industry lobby organizations are shifting attention to the role of parents so this is I guess helpful because it takes away the misunderstandings about gaming somewhat and our first advice is also from our organization is also for parents to play along with their children so they know what's going on and they can better coach and help their children in the game but for now industry is limiting its role to that so this is unfortunate I think because they are in possession of basically all the data and all the opportunities for meaningful intervention for example if a person is showing an excessive behavioral pattern of play this would be an excellent opportunity to provide some targeted reach out or provide channels to healthcare or basically even ask if everything is all right with the person but these types of more proactive interventions are not happening in this industry yet and even in the public debate there's some flat out denial that even something is going on which is unfortunate because in some cases there definitely is a match between the product and a certain personality type and then it clicks and people go out of control the product does play a role in that I guess a simple way to understand that would be extreme achievement types in games World of Warcraft for example went through a phase where you could only become a general by basically doing 24-hour shifts behind your keyboard and that really promoted excessive behavior so once they removed that people started playing less in that type of battle mode I think so they do they do have an influence and they can have a positive impact I think it's unfortunate they unfortunate that the debate is polarized in this way what we are personally doing now is like I said we have a website gameinfo.nl in this case we provide geomaterials about acceptance of gaming but also tips from pro gamers parents themselves to deal with gaming in a family setting we have a telephone line like I said we're also working on a better and new self-test that at least covers the new World Health Organization criteria and the DSM-5 criteria and we tend to operate with a stepped care approach where initially you try to promote a nuanced understanding of gaming there's many benefits but and I on the risks but if people do require professional help we also provide the opportunity to reach out to professional health care in the Netherlands so that's something we do and finally right now we're focusing on a healthy school and behavior program within which we're developing an e-learning module to help teachers recognize gaming problems in the classroom here in we have for example cases of students that might be sleepy in the classroom or they might be overly involved in gaming and we have some cases where the teacher is over-reacting but we also have some cases where something is actually going on in an effort to educate teachers about this issue and finally what we find very interesting is some teleprompter clicks here now sorry about that finally we're also working on early intervention programs like the Motiveer program which is an established program already but not scientifically validated in which a trained prevention worker goes into the school and if a student is experiencing problems for example with cannabis or in this case gaming they have four structured meetings using motivational interviewing to help the student change their behavior if they're open to change in our often-cased it's this tends to help really well so that's that's it I hope that's clear I'll be around for the panel and for questions anyway so I hope you enjoyed this thank you so I guess I see the first question from Moog Wheeler I'll be reading this because it's quite the question do you want me to read it or do you want to read it Tony um I can read it so you questioned you said that the high-addiction levels involve involved gaming rather than mobile phone use which you say this is because of the intensively immersive and comprehensive experience of the gaming environment oh it's dropping out chat box is disappearing oh it's a one-on-one question I guess no I'm lost where's the question uh there it is yeah um sorry guys that is the more you involve the whole body mind senses visual sounds social interaction adrenaline emotions physical action etc the worst the addiction the more complete the human experience the more gripping the addiction well thank you for that question I do have an opinion about that I would say generally speaking that games on mobile phones are designed to be played for a limited amount of time people tend to people tend to wear out on them after approximately four to five months and this is why every four to five months we have a new variation of garden scape or candy crush or those types of games they're just very fundamentally different than games in which you have more community building oriented activities and for example if you take world of warcraft first of all it's a role playing game so you tend to build something secondly there's a reputation mechanism so people respect what you do in the game and we only see basically we only started seeing more gaming addiction problems from the emergence of world of warcraft so right now any players with problems in the Netherlands anyway are are purporting those in relation to competitive play they decide they want to become esports persons and they legitimize using games for hours on ant in that way and eventually they figure out they don't have a chance but then they've already lost significant time and opportunities so your I think your hypothesis might make sense but from my perspective it has a lot more to do with the feelings of I guess competence relatedness and autonomy that people get in the game so it really fulfills a number of the number of their needs and it can create these types of games can create a sort of yeah like I said fish trap or a situation where you start over evaluating the worth of that online presence so does that make sense thank you I think so Joey Obama has a question for you he says how we define what is a game is changing a lot these days many would not consider themselves a player of games a few years ago but they now play casual games and are more accepting of games as part of their life and he wonders how this will affect humanity as a whole over time wow very interesting question I'll keep it pragmatic and maybe Nick Bowman who is far more schooled in these wide-ranging communication topics in relation to games can address that later on when he's on I would say that from my perspective there's just a bigger market for games right now so more demographics are being drawn into groups into gaming and we see this basically with Nintendo we was one of the primary examples for that and a brilliant one by Nintendo it's basically they started addressing exercise related crowds they started addressing elderly people very young people so there's really just simply a bigger market for the fortunate thing is that it tends to create more acceptance for games which is a good thing the unfortunate thing is that right now you see that the the biggest game companies tend to be acting a little bit opportunistically so for example we had a big scandal with the loot boxes last year where big companies are basically just they from my perspective they tend to just make make the money they can make as easily as they can which right now it is a gambling type opening of boxes in games and then they just figure out when what point people start complaining about it and then it's removed I think that's that's an unfortunate development in gaming which I don't really like so yeah it's not as fundamental as changing humanity we might in the end I guess in that sense virtual reality is one of the more interesting ones but I'm not really in a position to judge that but it might be for now just a niche area with that's definitely more or for fundamental game shift I think then right now gaming might be but that's just speculation and nick I think we're going to have to get to your question in the panel perhaps we can do that let's do a real quick answer for Katzai from Tony what about the problem with product makers that their profit motive is tied in with increasing commitment to the game and even perhaps addiction she's asking is there a need for regulation so the answer would be absolutely yes and it might be self-regulation so to the extent that I communicate with the gaming industry I tend to emphasize that I think it's really crucial that they start drafting some industry-wide ethical guidelines on what they do because well first of all like I said there's basically very big opportunities for guiding people towards care and nothing is happening so I understand it is a PR disaster if you get unilaterally connected with addiction but on the other hand if you seek people in your products with games with problems then I think you have some sort of responsibility to act on it from a social responsibility type of corporate activity if they don't then unfortunately the only alternative cause of action would be for governments to intercede and governments to regulate the industry which is unfortunate because that's pleasant but right now I can see it going in that direction because like I said the media debate is increasingly unfortunately polarized it's already happening by the way regulation so the the the Dutch gambling authority has moved to ban certain types of loot boxes from Dutch games or games that operate on the Dutch market and the Belgian gambling authority has done the same because loot boxes basically are in Belgian gambling and they fall under criminal law so they really have issues if they keep doing that. I will point out that Lee's comment is an important one it will be translated and kept in the transcript but unfortunately we're going to have to say thank you to Tony for this session because we need a little bit of time to set up for the panel and Tony's going to be on that panel so you'll hear more from him in just a little bit. So please thank our speaker and let's Tony we're going to get you off the stage because we're going to put chairs out there.