The World Health Organisation has included “gaming disorder” in its 11th Revision of the International Classification of Diseases (ICD-11). The effects of this could potentially ripple outward for years, and gaming industry bodies were quick to denounce the inclusion.
But for once, defenders of gaming as a favourite pastime don’t have the moral high ground they’re accustomed to.
It’s far more complicated this time. The World Health Organisation is right to lead the world in recognising the psychological link between gaming and gambling compulsions, with the two becoming more indistinguishable by the year.
As much as gaming organisations might feel it’s their duty to play defence, we’d do better to examine our less savoury practices that led to health organisations and governments intervening.
Let’s start by detailing what a “gaming disorder” is. While much of the attention from media and industry bodies has focused on “gaming deemed addictive,” you won’t find this language in the WHO’s decision.
There’s little room for misdiagnosis here. A gaming disorder diagnosis can be fasttracked in severe cases, but it’s heavily qualified, and the ICD-11 acknowledges that a “small proportion of people who engage in digital or videogaming activities” will meet the criteria.
According to the WHO:
For gaming disorder to be diagnosed, the behaviour pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.
The above is an almost universally accepted approach to identifying compulsive behaviour, and it rules out the vast majority of gamers. It’s not talking about little Jimmy who’s late to supper due to Fortnite. Or your mate Rebecca who genuinely preferred to skip the pub to raid Onyxia.
It’s talking about real people with a real problem, for which there has been an internationally recognised increase in demand for treatment. Citing this and new research, doctors involved in formulating the ICD-11 were able to reach a consensus on the inclusion of “gaming disorder.”
Legitimate questions could be asked like “Why not social media?” or “Why not the internet?” We may certainly see more of that in the future, as we grow a taxonomy for how technology affects behavioural psychology. Progress is slow, but evident — the ICD-11’s gaming disorder is a big step ahead of a previous attempt in the US which only included online games.
So what does this decision mean?
Let the Bodies Have the Floor
It takes years for countries to adopt recommendations by the World Health Organisation, and often these are implemented in an amended form.
The WHO’s new classification also doesn’t affect the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Published in 2013, this tool is widely used in the US and elsewhere to diagnose disorders. Importantly, the only behavioural addiction included in the DSM-5 is gambling. Videogames were investigated, but left out due to the need for more research, along with activities like sex, pornography, shopping, exercise, and food.
Should the future DSM-6 follow the now-confirmed ICD-11’s lead on videogames, of note will be whether it classifies it as an addiction, compulsion, or simply overuse. The three have narrower definitions than we see in popular media.
All that is to stress that the WHO’s decision is not a decisive strike of the gavel – more of a guideline – but the legitimacy of the WHO, combined with media pressure and a galvanised effort from governments worldwide to examine addictive practices in gaming has put industry bodies in a defensive posture.
An octuplet of organisations led by the European Games Developer Federation has presented a unified front in denouncing the inclusion, in a “Statement on WHO ICD-11 List and the Inclusion of Gaming.”
It’s a statement that reeks of narrative control, belittling the ICD-11 while simultaneously building it up as a threat. It’s highly selective in its quoted papers and pushes a false narrative in which science is opposed to the WHO. The statement reads:
We are therefore concerned to see ‘gaming disorder’ still contained in the latest version of the WHO’s ICD-11 despite significant opposition from the medical and scientific community. The evidence for its inclusion remains highly contested and inconclusive.
Look no further than the abstract of this statement’s own quoted paper to dispel the desired narrative:
We greatly appreciate the care and thought that is evident in the ten commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder.
Science isn’t with us, friends. Anyone who has studied the unethical aspects of game design knows there’s a dark side. It’s why developers have quit game studios for moral reasons. It’s why some game design courses now have an “ethics” section. The writing has been on the wall for years.
Nature Human Behaviour’s finding that 45 percent of analysed games met all five psychological criteria to be considered a form of gambling is just the most recent study connecting these two behavioural conditions.
Looking past the loose relationship with the truth when quoting science to scientists, it wouldn’t be the first time bodies like the ESA took an anti-consumer stance. We’ve written previously about its unwillingness to touch loot boxes. The pattern behind these stances seems less about protecting consumers, and more about protecting profits.
Closing Ranks Around a Sinkhole
Moral panics trigger a familiar reaction in the gaming industry, and we’re used to being right. We fought the Jack Thompsons of the world, safe in the knowledge that a causal link between videogames and violence has never been proven. We fought for accurate rating systems, knowing interactivity wasn’t training us to be killers and “sit forward” entertainment had many mental benefits over the “sit back” variety. We celebrate the positive ways games can heal, educate, and persuade.
This time, it’s different. There are bad actors we need to own up to, which will require educating the public.
Complicating things, the considered and legitimate WHO decision has entered a media tailspin with a more traditional moral panic around the phenomenal popularity of Fortnite. Segment after segment connected the WHO’s gaming disorder with parents worried about screen time — and use of the word “addictive” is where these clumsy conflations really start to go wrong.
It’s better than 20 years ago, but the mainstream media will always fumble and flail in its attacks on gaming, lacking the vocabulary to cut deeper than splinter. We’ve been handed a free straw man in Fortnite, but that doesn’t exonerate us. We need to respond to the best form of their argument — the one they didn’t even make. That’s how we remain credible and moral.
How long can we stand in front of broadcast cameras defending videogames without conceding there’s a sub-industry dedicated specifically to keeping players addicted? How long can we gloss over the fact that we, as an industry, deliberately sought techniques from behavioural psychologists and the gambling industry?
Much of what we’ve seen some pundits relaying to the public is still true. It is indeed a great idea to play with your children. And yes, what may seem to the outside world like gaming addiction could just be escapism. Gaming is good at that. It can be therapeutic, destressing, and social.
But as the world of psychology necessarily explores gaming’s more predatory aspects, it’s not the role of industry organisations to refute the WHO as if it’s another sensationalist provocateur. Better to work with it. We’ve been holding onto the moral high ground like it’s King of the Hill, and in the end, it’s the hill our credibility will die on.
The Wrong Side of History
If you can accept gambling addiction is real, or behavioural addiction is real, you can accept gaming can be a disorder. Critics will say any behaviour can be addictive to the right person. And sure, psychological tricks are employed in retail, website design, loyalty schemes, and more.
But how many can you name with the psychologically optimised reward schedules at play here? Using the same exploitative techniques, it’s fitting that gaming joins gambling as a non-physical disorder duo.
Ever since games became a service and subscriptions were introduced, maximising playtime brought out the most cynical of reward structures. The evolution of spending money as well as time has brought us from rigged dice to rigged vice. Genres blend, progression systems proliferate. Players become more concerned with their virtual numbers than the act of playing.
Publishers are good at what they do, and some act cynically. Some don’t even pause to ask if it’s unethical. As Ian Bogost (who recently had his own take on the ICD-11) once told us:
What are we doing to the people to which we’re giving these games that we’re making? Are we asking them to participate in a pattern of activity that may or may not be destructive? Self-destructive? And it doesn’t really matter whether or not it’s kind of clinically destructive to me, it’s more a matter of is this the sort of world that we want to live in? One in which we click a button on a mouse every few minutes because we’re worried about losing our crops in Farmville? For me personally, that’s not a desirable experience to create. For others, they don’t even ask that question. It’s like ‘Well, this is the trend, this is the thing, this is what’s hot. If we don’t do this, we’re going to miss out. We’re going to lose out.’
We all play a part in this. When we wholesale deny the addictive properties of games, the WHO and the public would be right to lose faith in us. Just another industry like big tobacco or slot machines before it, protecting a vice as lucrative as it is predatory.
There’s some positive work done by these organisations. But after subservient, one-sided stances on loot boxes and the new gaming disorder, they’re in danger of becoming industry mouthpieces at odds with their own consumers. It’s a dangerous industry to have your cake and eat it too — gamers know the cake is a lie.
As a game designer, you can make your own decision about whether you care that what they want is not good for them, or whether you want to exploit their susceptibility to vice and profit from it. My personal, gut feeling is that all this Farmville-type stuff is just evil. It’s not even mildly evil. If you look at the discussions between people at those companies, it’s about ‘How do we get people thinking about our game, all day every day, and get them to buy the maximum number of things, and give them the minimum amount of utility in real life?’ Because if they get a lot of utility out of it, they get satiated.
It’s disingenuous at best to claim “the science isn’t in yet” when unconscionable corporations, in the name of retention and monetisation, employ this scale and complexity of manipulation — not to mention blatant and unregulated gambling systems.
The difficult job ahead involves understanding, communicating, and regulating the different ways our brains can be manipulated. Some games are worse than others. Some seek to satisfy our compulsions, whereas others seek to manipulate them. As we’ve learned from the manipulative side of the gambling industry, so should we learn from its socially responsible measures.
Loot boxes are the most easily accepted parallel to gambling, but the Skinnerian and Pavlovian reward structures are harder to communicate. As we’ve endlessly said – and as the Netherlands and Belgium most recently demonstrated – if gaming bodies are unwilling to self-regulate, governments around the world will step in and do it for us.