Inside the Indonesian Hospital Treating Gaming Addiction

This article originally appeared on VICE Indonesia.

Riqsa, now 15 years old, is used to having things his way, which includes spending eight hours in front of a screen daily. He began playing online games when he was 8 years old, initially for an hour or two a day.

At first, he would spend Rp25,000 ($1.76) on data plans, online games, and in-app purchases weekly. Then his expenses doubled to Rp50,000 ($3.52), eventually peaking at Rp100,000 ($7.04), a sum that can put significant financial strain on a lower-middle class Indonesian family. Riqsa’s parents had not factored in the expense into their monthly budget. When he didn’t get his weekly gaming budget, he would throw a temper tantrum and break things.

At one point, Riqsa’s parents pulled him out of school for threatening a classmate with a knife during a disagreement. He no longer appeared to be emotionally stable, so his parents admitted him to the Cisarua mental hospital in East Java.

Riqsa has been under the hospital's care since mid-January. When VICE met with him, he was playing a keyboard in the hospital’s playroom.

"Hello, my name is Riqsa," he said politely, extending his hand.

“Do you miss playing games?” I asked.

“No, not anymore,” he said. “I’m allowed to go home today. I’m waiting to be picked up.”

Riqsa’s psychiatric evaluation revealed that he was depressed. He had been bullied in school and immersed himself in the world of shooting games as a coping mechanism, said Riqsa’s psychiatrist Lina Budiyanti.

“He had no self-esteem. He withdrew himself from his circle of friends and found a new identity in his gadgets,” Budiyanti told VICE.

Patients live by a tight schedule in Cisarua. On Mondays, they exercise. Tuesdays are craft days. Wednesdays they spend outdoors. On Thursdays, the patients study and attend classes. Fridays are reserved for prayer, while the weekends are packed with movies, playing, and music.

Arimbi Nurwiyanti, head of the hospital's child and teen division, said Riqsa has made significant progress. He is now able to better control his emotions and function in social settings. In addition to psychosocial therapy, patients like Riqsa also take medication.

Inpatients who complete their therapy may continue to visit the hospital as outpatients to monitor their progress. But the medication and therapy can only do so much if parents don’t change their mindsets about their children, Nurwiyanti said.

“The most important form of therapy is teaching emotional and behavioral control,” Nurwiyanti said. “Doctors will not succeed if parents are not supportive of their child’s recovery.”

A new study published in the journal Addictive Behaviors found that internet and gadget addiction have similar effects to drug addiction. Researchers from the University of Heidelberg in Germany studied the brains of 48 adults using an MRI scanner; 22 of them gadget-addicted, 26 of them not. The gadget-addicted group exhibited physical changes in their gray matter, the part of the brain responsible for controlling muscle movement, senses, emotions, memory, and decision-making.

Between December 2019 and January 2020, the Cisarua mental hospital admitted 12 outpatients for gadget addiction. During the same period, the hospital, in collaboration with another East Java hospital, treated 180 individuals as outpatients.

“Every week we treat dozens of patients with gadget addiction, but not all are inpatients,” explained Budiyanti.

The hospital follows three steps before diagnosing a patient with gadget addiction. They first interview the patient in a process known as anamnesis. Next, they interview the parents separately, which is called heteroanamnesis. Lastly, the patient undergoes a psychometric test in the form of a questionnaire.

Only patients exhibiting co-morbidities will become inpatients, especially if they are deemed to be a danger to themselves and others. Patients have comorbidity if they have an accompanying disorder in addition to the main disorder. In Riqsa’s case, it was depression and social anxiety. He had difficulty socialising and his academic performance declined.

“Many gadget-addicted patients also have those disorders,” Budiyanti said. “They have trouble functioning emotionally.”

The hospital treats patients from a wide variety of age groups, from toddlers with speech delays because they watch too many videos, to teenagers like Riqsa. Teenage boys are more susceptible to gadget addiction than teenage girls, Budiyanti told VICE, adding that 90 percent of the gadget-addicted patients she has treated were addicted to first-person shooter games.

Budiyani also explained the complexity of factors that can influence the development of gadget addiction. Permissive parents who give into their child’s every whim, coupled with poor communication, can significantly contribute to addiction. Internal factors in the children themselves and traumatic experiences can also make gadget addiction worse.

“When the child does not feel appreciated, perhaps academically, they will pursue a coping mechanism to gain validation,” said Budiyanti. “Online games provide a space for such validation.”

“It was mid-2018 when we first received the medical guide on the matter from the World Health Organisation,” Budiyanti said. “Before that, it’s likely that many patients had undiagnosed gadget addiction.”

This guide is the 2018 International Classification of Diseases 11th Revision (ICD-11), which describes gaming disorder as a control disorder in which gaming takes priority over an individual’s other activities.

The number of internet users in Indonesia reached 171 million in May 2019 according to the Indonesian Internet Service Association. Hootsuite and We Are Social reports revealed that Indonesians are fifth-highest in the world when it comes to time spent online, at an average of eight hours and 26 minutes per day.

Indonesia’s market for online games is massive. Data from the Indonesian Gaming Association (AGI) reported that the country’s gaming industry generated Rp14 trillion ($982.5 million) every year. Director of PUBG Mobile Southeast Asia Oliver Ye said Indonesia has the second-highest number of PUBG players in the world, although he did not give an exact number.

The Indonesian government has been pushing for the development of e-sports through various competitions like the President’s Cup, without raising awareness about gaming-related mental health issues. In late 2018, the government announced it was planning to issue a regulation to combat gadget addiction. Two years later, it’s still non-existent.

The solutions the government does take have been controversial and mostly ineffective.

In 2019, an Indonesian mayor launched a “chickenisation” program that involved giving primary school students live chicks to take care of in an effort to prevent gadget addiction.

The program was tested on 2,000 students, resulting in the death of dozens of chicks and inviting criticism from organisations like PETA.

If the government increased awareness about gadget addiction and provided more spaces for children to receive preventative treatment, perhaps cases like Riqsa’s and the child who was locked in a cage for his gaming addiction, could have been avoided.

As Riqsa readied himself to return home to his family, he left me with a poignant remark: “I just want to go back to school.”