Everyone (especially growing kids) should prevent screen time from replacing creative, physically active, and social endeavors. The digital world has unfortunately facilitated new addictions (gaming, social media, gambling, trading, online sex), seen primarily in young and adult males. Innovative support (re)builds physical and social health, and a suite of life skills, for a balanced life. Parents and young men will find this episode helpful.
Hilarie Cash, Ph.D., LMHC, CSAT, CPGC Co-founder, and Chief Clinical Officer of Restart Life.
During This Episode We Discuss:
- Gaming addiction, loss of control.
- Content addiction delivered by the internet.
- Addiction to internet content begins early.
- Isolation and predisposing conditions makes someone more vulnerable to screen addiction.
- Games appeal to guys, the competitive nature of the games.
- How to recognize if someone is addicted to gaming.
- Treatment options and resources.
- Success stories.
“Look at what it is that has fueled their choice to isolate in front of the screen, rather than dealing with the things they need to be dealing with. The choice of isolating in front of the screen has led them into now an addiction and they are really trapped there.”
“Guys seem willing to spend hours and days engaged with the game in front of a screen essentially isolated from human contact.”
Hilarie Cash, Ph.D.
- Families managing media: screenstrong.com
- Sex and love addicts anonymous. A 12 step program built and designed to deal with problems of intimacy.
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Dr. Richard Pelman(01:22):
In today’s episode, we have the pleasure of interviewing Dr. Hilarie Cash, PhD, mental health, counselor co-founder and Chief Clinical Officer of Restart Life. Restart life is the first residential entrance mission program treating internet and video game addiction. Dr. Cash. Welcome.
Dr. Hilarie Cash
Happy to be here.
Dr. Richard Pelman
We had a prior episode where we looked at dependency and addiction, primarily about opioids. Thinking about addictions. There are many other types of addictions, sexual health, addictions, gambling, addictions. I was unaware that people got addicted to the internet and video games. Give us a little background and your specialty and how you came about with expertise in a program that is really dedicated to internet and video game addiction.
Dr. Hilarie Cash (02:07):
I first moved to the area back in 1993 and opened my private practice in Seattle in 94. One of my earliest clients was a young man of 25 who had already lost his job at Microsoft. He was losing his marriage and his second job, and it was all because he could not stop playing a multi-user domain game of Dungeons and Dragons. And this was for me a complete revelation because I knew nothing about the internet really, except what I might’ve heard on the radio. And I certainly didn’t have a computer of my own. So, this was just a window into a universe that I knew nothing about but was very intrigued by I had my own young child at the time. And I was just somewhere in the back of my mind, thinking, I need to understand this because I have a feeling. This is, I’m seeing the trickle before the flood.
Dr. Hilarie Cash (03:02):
My awareness around this was increased by other people coming in, just over those early years of the mid-nineties with essentially what was clearly addiction to some aspect of the internet. Somebody was a day trader. Somebody was very addicted to their writers’ forum online and the affair that they were having with somebody, somebody else addicted to pornography, more gamers coming in. And what was the reason I understood it to be an addiction that they were struggling with is that their lives were falling apart. As a result, they could not stop themselves engaging in these ways, whatever those ways were back then there were very, very few people who were noticing it and talking about it and writing about it, but there were a few. And so just over the nineties, I was developing some expertise in this and talking to the other therapist that I was able to find who were also noticing this and worried about it and trying to learn about it.
Dr. Hilarie Cash (04:04):
So, we were teaching one another about this, really at that time, and back in 99, I started at a place called Internet and Computer Addiction Services. It was an outpatient clinic and the person that I co-founded it with Jake Parker was mostly interested in sex addiction and working with sex addicts. And I helped him by working with the partners with those sex addicts, but always interested in and concerned about the lack of treatment options for people who needed a higher level of care around video gaming. This was before social media really became a thing, but we nonetheless still had those internet and video game addicts. And I was just lucky in 2009 to meet, Rossette Ray, and her husband, and we were able to start this and provide that higher level of care, which was unavailable anywhere else.
Dr. Richard Pelman (04:57):
Okay. When does something move from a vice or a habit or a free time event to something that is totally addictive?
Dr. Hilarie Cash (05:07):
To understand addiction, be it a chemical addiction or a behavioral addiction, is that loss of control, the inability to stop, even when you recognize that it’s doing harm to your life. And that’s the critical thing. And because it’s doing harm to your life, an addict’s life spins more and more out of control when it comes to the behavioral addictions that are facilitated by the internet, the internet is the delivery system for the content. And it’s the content, which is addictive. So for some people, it is sexual content and we would call them sex addicts for some people it’s video games, they’re video game addicts, social media addicts, gambling addicts. These are all behavioral addictions that are being by access to the internet. And, because now we have smartphones, that has simply increased access to those drugs. Some people are addicted to multiple aspects of the internet and other people sort of keep their interests more mono focused.
Dr. Hilarie Cash (06:16):
But most of the people we work with here have been handed their delivery system and the drug by their parents when they were very young and parents not knowing what they were doing, having really no clue about the addictive potential are these days handing their kids, you know, smart phones and gaming systems that deliver this potentially addictive content to people who don’t have basically a prefrontal cortex, which is the seat of that ability to control impulses and think about consequences. Think ahead. These are children they’re incapable of that. They need parents to provide that function. Parents do provide that function for the most part. When it comes to drugs, including alcohol, parents know you don’t hand drinks to your little kid, but parents have no clue at all about the problems with gaming consoles and unfettered access to the internet. And so kids of a very young age are getting addicted.
Dr. Richard Pelman (07:17):
Do most of these people really start out in childhood? Or is this something that you find in your clientele could come along later in life?
Dr. Hilarie Cash (07:26):
It’s interesting when we reflect that we here at Restart, who’ve been doing this a long time and we reflect about the profile of the clients who were coming to us 10 years ago, and the profile of the clients coming to us now, many aspects of that profile are still similar. But back then we had a lot more young adults who really didn’t start heavily using the internet and video games until they were actually older teenagers, 16, 17, 18, 19. That’s kind of when they just jumped off the cliff and fell into, into an addiction. And so when you’ve got somebody who doesn’t really start problematic use until then they have a memory of what life is like. And they’ve been developing in many normal ways up until that point. And they have a memory of having played sports, and having learned musical instruments, and playing tabletop games with their friends, and getting together and being outdoors, and running around, and so on and so forth.
Dr. Hilarie Cash (08:38):
But what we’re seeing is more and more adults coming to us who really don’t have those have not had those experiences. Fewer and fewer have had those experiences because they have in fact gotten hooked when they were young in early elementary school often. And that’s where they have spent their free time, rather than being physically active, learning other hobbies, developing their social skills. Instead they have just been online and in front of screens and so forth, they don’t have memories of really kind of what life was like without. And so for them, the damage is much deeper and they have a much longer recovery period because they have to develop interest in the world.
Dr. Richard Pelman (09:30):
Let’s look at an adult or a young adult who’s out into a career that perhaps there’s pressures at work. Maybe there’s financial pressures at home, maybe relationship issues. Aren’t working out. People try to deal with that. We would suggest that if it gets too bad, they see somebody to help them with those therapists are available. But when would somebody take a path where they would isolate themselves in front of their computer.
Dr. Hilarie Cash (09:58):
When somebody has a problem and they go seek help, the therapist is going to take a history and really like, look at what it is that has fueled their choice to isolate in front of a screen, rather than dealing with the things that they need to be dealing with. And that choice of isolating in front of the screen has led them into now an addiction. And they’re really trapped there because they can’t get out. You know, it’s that loss of control. If they don’t start having that problematic use, then there’s no knowing what it is. That’s led them there. They might have a co-occurring disorder; they might be depressed. They might be anxious. They might have ADHD. These are all conditions that predispose somebody to want to escape the pain of those conditions. And those conditions make them more vulnerable, certainly PTSD and childhood trauma.
Dr. Hilarie Cash (11:01):
Even if it’s a small “T” trauma, which is sort of chronic and less noticeable as trauma, all of these things make people more vulnerable. These are the kinds of conditions that might lead somebody who is very young to go toward screens and the escapism that they can escape, that they can find through a screen. But if we’re talking about somebody who really hasn’t been escaping until they’re older, they actually have relationships. They actually have screens. They actually have careers and relationships in their lives. Then we just have to look at whatever it is that that made them vulnerable. But again, screens are everywhere. They’re ubiquitous. We hold them, we hold powerful computers in our hands and call them phones. When they’re really not phones, they’re computers, you put those together and you might find somebody uses that as their escape from pain and difficulty.
Dr. Richard Pelman(11:58):
Going back to looking at childhood development, where a child is exposed to computer games and the availability of looking at a screen. Now that child goes to school has interaction with a peer group. Maybe has some outlet time where they can be physically active, maybe is in a sport that comes home and gets a computer. Are they in the same room?
Dr. Hilarie Cash (12:28):
If you have a child who goes to school, first of all, schools are giving screens to kids. So kids are spending a lot of free time when they might actually be outdoors, running around and playing actually with screens still. So again, availability, screens are made available. They’re available to kids in schools now. So they might spend much less time than you would think, actually running around and socializing. They may find some other nerds who are, that they can sit around and talk. Non-stop about video games and sort of keep those neuropathways very activated. If they’re already addicted to video games, let’s say, and they’re sitting around and there, they’re talking about the video games and they’re keeping all of those pathways very activated. And so, again, even though children are going to school, it doesn’t mean that they’re necessarily really having good, healthy experiences that take them completely away from screens and allow them to experience all these other facets of real life that they need to be experiencing. They should be experiencing, we want them to be experiencing, but they might not be really active.
Dr. Richard Pelman (13:45):
So are the educators aware of that potential?
Dr. Hilarie Cash (13:48):
Not enough, not enough by any means. There’s a wonderful book. I can recommend to those who are listening called “Screen Schooled.” And it’s really looks at the history of how screens have been pretty uncritically adopted by schools. And it’s a whole cultural thing. It’s like, this is how we’re going to put our kids ahead without actually paying enough attention to the science, which is showing the detrimental effects of too much screens in schools. So no educators, I think a lot of them are not thinking critically enough about the effects of screens in school.
Dr. Richard Pelman (14:27):
Are the majority of your clients, men?
Dr. Hilarie Cash
Dr. Richard Pelman
So, then delve into that because there’s somebody driving right now, who’s listening and in your commute is going to go, huh? So it’s playing a little bit.
Dr. Hilarie Cash (14:40):
Well, you know, I don’t know of any research that’s been done that would explain why it is that we get very few calls from women seeking our services. So this is speculation on my part about why we’re working with men primarily. In 10 years of running an adult program, we’ve had eight. (Women) It’s pretty true. It’s pretty dramatic. Yeah, it’s so weird. I think that part of it probably is biology that games are built as boys and men I think are, are drawn to the competition and challenge the games. And the games are very carefully designed to appeal to that. The competitive urge games are very well-designed to appeal to guys, women play games, but they tend to play more casual games and more cooperative games. And I think that those games are not as addictive as maybe the games that the guys are playing.
Dr. Hilarie Cash (15:51):
And also, I think men are just garnered from the conversations I have with our clients. They seem willing to spend hours and days engaged with the game in front of a screen, essentially isolated from human contact, but so drawn into that fascinating competitive world that they’re engaged in. Whereas I really do think that women feel a stronger urge to be face-to-face in a relationship and are unwilling to be so isolated in front of a screen for four days on end. And that social connection drive ends up being a protective factor. So that’s what I think, but I don’t know if I’m right, certainly the games that are highly addictive and they’re addictive because there are multiple layers of reward built into the games. It’s also a misogynistic culture. The games themselves have a lot of tendency to be misogynistic. There’s a lot of misogynistic content to the game itself that’s been built in, but also the culture of those playing.
Dr. Hilarie Cash (17:05):
It tends to be pretty misogynistic, and women often don’t feel welcomed into those spaces or really safe in those spaces. And so the women I talked to for the most part tend to avoid playing those games, or if they play them, they pretend they’re men so that they don’t have to deal with how they’re targeted in the game. Let’s just talk for a moment about physical health. In many realms folks, we work with tend to come in, almost all of them, universally severely sleep deprived. But in addition, they’ve been consuming fast food and soda… caffeinated soda. And so they have not been gaining the nourishment their bodies need. Often for years. And, they’ve been extremely sedentary for the most part. And so they have really, really some very, very serious health issues as a result: diabetes, or they’re pre-diabetic, severe vitamin D deficiency, they’re often very overweight, or extremely underweight because they, you know, they just haven’t felt appetite or haven’t been willing to respond to their body’s appetite because they’re so engrossed in what they’re doing online. But it’s part of what we try to do here is really address their physical health needs. And it’s not unusual to see somebody lose a tremendous amount of weight over the course of being here or gain a tremendous amount of muscle weight over the course of being here because they’re, you know, we have a fitness program and they’re getting physically fit.
Dr. Richard Pelman(18:41):
If there’s parents listening who have little kids. So let’s just go back for a moment. What would your advice to them be about how much time they should allow their child to be in an interfacing, a video game or a screen?
Dr. Hilarie Cash (18:54):
I have a recommendation for a couple of websites that they can go to. And a couple of books that they should read. One website is called Families Managing Media, and they really ought to go there because they can get a lot of good information. And a lot of support. Another is called a Zone In, with a .ca for Canada, and Chris Rowan has wonderful resources. And she and I, and someone Dr. Andrew Doan developed a nice handy-dandy chart that really says, okay, if this is your child’s age, then this is the kind of, this is the amount and type of screen content that you should be allowing. And so it’s a very handy guide for parents to help them understand that, children should not be having the kind of access to screen that in reality, most children are having. And so anyway, those are two websites.
Speaker 3 (20:03):
And a fabulous book, which is good, and not only for parents whose children are not yet having trouble, but for parents also, whose kids are having trouble, is by Victoria Dunkley. And it is called Reset Your Child’s Brain. And what I like about her book is that she really reviews the literature in great depth on what the research is that’s been done and a lot has now been done and what it tells us about what children need and the effects of too much screen use on children. So that’s a really super book and there’s a book called Glow Kids by Nicholas Kardaras. That’s one of now a growing number of really very good on this subject. But I think the thing that parents need to hear maybe who are listening to this is that they need to really become conscious and think about their own screen use. They are modeling, and there are many, many, many parents who sort of endorse the idea that, yes, my kid’s screen use should be limited because I figured out that their development will be enhanced if they don’t have too much screen use, but the parent himself or herself is nonetheless on their own devices constantly.
Dr Hilarie Cash (21:23):
And so parents need to really challenge themselves to put their devices away, turn their devices off, and really have sort of set and carefully thought through times when they will use their own devices.
Dr Richard Pelman (21:37):
I imagine if somebody has been in front of a screen for many, many, many, many years and isolated, they may be happy being isolated. They may be happy, that fulfillment in the world, their environment is the screen, whatever they’re watching on the screen. So why would somebody, all of a sudden decide I want to give that up?
Dr Hilarie Cash (21:56):
Usually what has happened with the adolescents a little different, and I can describe that to you, but what’s happened for almost all of our adults is that they have failed out of college, and they have lost scholarships. They have wasted a great deal of money that their parents have spent. So typically that’s when parents find us, parents say, okay, we see that there is a huge problem here. You just failed out of college. And you came home and you’re not, in fact you promised, you’d go get a job. But in fact, you’re not out there getting a job, or maybe you’ve gotten a job, but you just got fired because you didn’t show up for your work. So clearly you are not managing your life. And we are worried. You’re isolating in your bedroom, down in the basement. You’re not socializing. We can see you’re physically unhealthy.
Dr Hilarie Cash(22:52):
You seem to be depressed. You know, we’re worried. And that’s when it’s usually parents who contact us and they get their adult child to us in a few different ways. Sometimes it’s just a matter of having a firm clear conversation and saying, we’re worried about you. And we found a place we think would help you, and we want you to go. And sometimes that’s all it takes, but denial, which goes along with addiction, I think of as a big plexiglass bubble around somebody and it distorts everything. So if that plexiglass bubble is thin, that kind of a conversation is sometimes all it takes for the bubble to fall away and the person to say, okay, you’re right. And I’ll go get help. If it’s thicker, they may have to take stronger action. And sometimes that is to hire an interventionist who actually come and hold a formal intervention like you do with a drug addict. And sometimes it means a tough love approach of saying, we’re not going to enable this addiction anymore. You’re going to have to move out and we’re not going to support you. You’ve got to make your way in the world, or you can go for treatment, but it’ll be one or the other. So that’s usually how people come in.
Dr Hilarie Cash (24:08):
The adolescent situation, what’s happened is that the kids are starting to refuse to go to school and they are just holding up in their rooms. You know, they’re big now they’re 15, 16 years old, 14 parents. Can’t just physically hold them to the car. They, you know, parents feel quite powerless to get, make their kids go to school. And so the kids are starting to refuse to go to school. These are usually bright kids, and their grades are just plummeting. And there’s a great deal of family conflict. And it’s not unusual for the conflict to get violent and for police to have to be called and you know, parents to say, oh my gosh, you know, this has just spun so out of control, and clearly, we are unable to handle this situation.
Dr Richard Pelman (24:56):
And so, and you also have referrals from other therapists. Somebody goes to a general therapist who says there’s actually a specific recovery group, right. Which is right. Restart. Tell us a little bit about your program and tools that somebody may not be aware of.
Dr Hilarie Cash (25:13):
The best tool of all is being away from screens for a prolonged period of time. So be they adolescent or adult when they come to us, they spend a minimum of two months away from all screens. And so during that time, the brain is up regulating to normal function that they’re going through withdrawal and a break elating. And once they have done that, and we’ve seen on average, it seems to last about three or four weeks. But at the end of that time, they’re feeling so much better. And they report feeling so much better and clearer thinking. And while that’s happening, we’re also giving them healthy experiences. So they’re eating healthy. We have lights out at a reasonable time and they have to get up at a reasonable time and they’re exercising. And they, the adults, land first at our ranch. And so they’re, they’ve got chores to do.
Dr Hilarie Cash (26:07):
They’re looking after animals. We have goats and horses and chickens and a dog and cats. And so they’re beginning to shoulder responsibilities there. We find that they often have a lot of empathy for the animals. They start really caring about the animals, but it’s a pretty low demand period. They come in here once a week for a counseling session. But most of the time they’re just, they’re mellowing out socially interacting. They’re no more than six at a time there. So it’s this safe social environment. They have books to read. They have assignments of books to read, some writing exercises to do, but all of it is designed to get them thinking, reflecting as detox. They go from there to Heaven’s Field, which is in Fall City. And now they come in here four days a week and they’re having multiple groups a day and at least one therapy session, sometimes more than that, depending on what they feel they need.
Dr Hilarie Cash (27:07):
And now they’re diving much deeper into their work. And they’re starting to look at the family dynamics that they came from and they’re learning. They’re really learning social skills and organizational skills, you know, try because many of them don’t have a well-developed prefrontal cortex. And so they are not, their executive functioning is not very good. So we’re trying to teach them time management and organization and planning. So they’re working on many, many, many different things. The idea is that by the time they finished the intensive part of the program, that they’re going to be ready to function as adults in the world. And that’s our transition programs. So they, before they can transition, they’ve got to also have a good plan written. We call it the “life balance plan.” They have to really think through how are they going to reconnect with screens and the internet, and how are they going to manage that once they have a good plan in place and they are fully engaged in the program, we can see that they’re functioning well.
Dr Hilarie Cash (28:10):
And they have a recovery mindset. In other words, they know they have to live as addicts in the world, addicts in recovery. Then they’re welcome to come into the transition program. And in the transition program, they’re living now just down the street in apartments, that restart leases and they rent, they pay their share of rent. They’re getting part-time work, and they’re coming here to play. You saw the ping pong and the music room and all of that. They come here to enjoy themselves, to do their multiple groups and their therapy. And they can now use our computers in our computer lab for up to two hours a day. But those computers are monitored. We’re holding them accountable to the agreements they’ve made about how they’re going to use the internet going forward. That lasts about on average six months, it can last longer. And then we have a final program called “Sustainability,” where they move out. They find some buddies, they go and they sign their own lease on an apartment. And now they’re working full time, maybe part-time. And back in college, usually they start off at Bellevue college and they buy now when, once they’re in “Sustainability,” they often have their laptops back and their smartphones fully functional because they’re demonstrating that they are able to live sensibly as men in recovery.
Dr Pelman (29:31):
And somebody who is in that situation, that isolated, how long does it take before they can even begin to delve into developing relationships?
Dr Hilarie Cash(29:39):
What we find is that can develop relationships. Initially the relationships they get comfortable with are with one another in the program, right? First, it’s in that just six people at a time. So it’s not overwhelming and they’re learning to relate. And, and they’re coached all the time by the staff in how to relate, how to handle conflict and that kind of thing. So that’s the beginning. And then as they start coming here, they’re now interacting with the larger community of Restart clients and having to, you know, get comfortable now with more people and more hustle and bustle when they go into the transition program, they’re now as people out in the world working, I mean, it’s, it’s difficult. It’s truly difficult for them because they’re so socially anxious. And so, you know, some of them avoid for a long time getting the job, you know, they’re coming up with excuses to not take on that challenge, but eventually they all do. And that’s often a real turning point for them because now it’s not just other addicts that they’re interacting with. Now they’re out in the world, really interacting with just normal folks and, discovering that they can do it. And it’s an incredible boost to their self-esteem to discover that they can in fact do it. The biggest challenge comes a year down the road when they would like to date. And then, oh my gosh, this is just, and so it’s a, it’s a long slow process.
Dr Pelman (31:17):
Yeah. I was going to get into personal relationships because that by extension of just being out in the world would seem more difficult if they haven’t had the opportunity to do that. That’s right. It is not just that you’ve had success. So somebody shouldn’t just throw in the towel.
Dr Hilarie Cash (31:32):
No, no, no, no, definitely not for somebody who doesn’t come to Restart, I strongly recommend if you’re somebody who’s fearful out in the world and you tend to be avoidant, there’s a wonderful 12 step program that I recommend and it’s Sex and Love Addicts Anonymous. And that is a program that really is built and designed to deal with problems with intimacy and starting with the intimacy between, you know, this just nonsexual. Non-romantic just the intimacy of a good friendship, a good support person. And then that can expand. I mean, through that program, you really are guided in how to begin dating, developing a dating plan and how to do that. And you’ve got a sponsor who’s there right there in step with you helping and supporting all the way. And our guys, we really encourage them to do that 12-step work.
Dr Pelman (32:31):
And the name of the program, again?
Dr Hilarie Cash (32:34):
It’s Sex and Love Addicts Anonymous,
Dr Pelman (32:37):
Sex and Love Addicts.
Dr Hilarie Cash (32:39):
There are quite a few good meetings. And so I strongly recommend that for somebody who doesn’t come to Restart, but really wants to deal with their fear of intimacy and their lack of understanding about intimacy and what it’s all about. How do you achieve it? That would be the program.
Speaker 2 (32:58):
Oh, this is fascinating. It’s a world. I had no idea existed or knew about. Any closing thoughts?
Dr Hilarie Cash (33:04):
There’s a term that I really love, and it’s called “Limbic Resonance” and Limbic Resonance refers to what happens when two people who are friends are face-to-face with each other in, or, or physically present with each other, interacting in a way where both of them feel cared about and say, it releases a whole bouquet of neurochemicals in both of our brains. And those neurochemicals keep both of us regulated both emotionally and physically and babies need it all the time, but adults need to just, well, it’s not as though we outgrow our need for it. It’s our birthright. As social animals, we need that. The research is very clear that the more time people spend online, the more dysregulated they become emotionally and physically, there’s a strong, positive correlation of depression with screen. It does not fulfill screen socializing, being online, even if you’re socializing online is not an adequate substitute for the face-to-face in-person relating that we actually need, because that’s what generates and creates the limbic resonance. And if you’re somebody who doesn’t have the social skills to create that successfully, you need to seek help so that you can develop those social skills. You still can learn, and you can learn, but you have to learn in a different way. You have to get coaching around it and maybe therapy around it. But you can learn because that’s where your deepest and truest needs are going to be met is in those face-to-face relationships.
Dr Pelman (34:50):
Well, I truly appreciate your sharing information with us. I hope the listeners have found it rewarding. It’s fascinating. So, thank you. It’s been my pleasure.
Dr Pelman :
This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society. Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.