Blast from the Past: The Game Doesn’t Care: Why the Gamification of Mental Health Isn’t Working (Yet)

This post is from 5 years ago, July, 2013. I believe we’re all still thinking about and struggling with these same issues today! 

Games that are not games. There is a serious barrier to the effective gamification of mental health. This barrier is that the games we psychologists and health professionals are coming up with are not fun. In fact, they are totally uncool, border on the condescending, and wouldn’t motivate anyone to play for more than 30 seconds. This is the case even though the bar is set quite low because these “games” address things that people really want, like boosting our intelligence and memory, reducing depression and stress, quitting smoking, … fill in the blank. I’ve been fascinated with this disconnect between Psychology’s view and real-world acceptability. This disconnect is plaguing other fields as well, such as in the development of “serious games” for education. In this larger context, I’ve been working on the development of an app that takes a scientifically proven approach to reducing stress and anxiety, and embeds the “active ingredient” of this intervention into a game that is fun – fun enough, we hope, for someone to want to play for much more than 30 seconds.

Fun versus health goals. In the midst of  this ongoing development process, I had the pleasure of speaking with Nick Fortugno, co-founder of the game design company Playmatics. In addition to creating really fun games, like Diner Dash, he has created games to promote positive social change and is one of the visionary and forward-thinking advocates for the idea that serious games can and should be fun. So, he has a deep understanding of the barriers facing the gamification of mental health. As we were talking about these barriers, Nick said something that really got me thinking. He said, when we design games for education or health, we have to remember that “the game doesn’t care” about whether we’re making progress towards our goal. In other words, a game isn’t fun because it meets some criterion that we, the developers, have for success – like boosting our ability to remember, reducing symptoms of anxiety, or losing 5 pounds. A game is fun because it creates an aesthetic experience and facilitates game play that we want to come back to again and again. Therefore, I would argue that a “serious” goal embedded in a truly fun game is reached as a by-product of the fun.

The need for backward engineering. I think I am accurate in saying that very few people, myself included, who are trying to create serious games for wellness think like this – i.e., like a game designer – about the process of gamification. From what I can tell, game designers think very deeply about the experience they want the game to promote, and then they work through the pragmatics of the game play that will facilitate this experience. This backward engineering from the point of view of the aesthetic/experiential goal to the pragmatics of the game is the opposite of what psychologists do when they think about gamification. Instead, we have parallel streams of development in which (a) we know that our “game” (read scientific protocol) is truly boring, and (b) we have to somehow decrease the snore factor. We think: “Hm, here is my very rigid experimental protocol/computerized intervention. I must overlay this protocol with some cute little animated guys, perhaps with a fun back-story (wizards? aliens?) and then make sure users get points when they conform to the requirements of the protocol.” Sounds thrilling, huh? So fun? Exactly the recipe for the next Dots? Right…. So, we have a lot to learn from game designers, and I believe that crucial to the future of the endeavor of gamifying mental health is partnering with people who know how to create fun and understand the process of game design.

Pocket rituals. What would it be like if we created mental wellness tools, or even interventions for serious mental health problems, that were truly fun and that could become part of our array of habits and strategies for feeling better, reducing symptoms, performing more efficiently, or dealing with stress?  These games, if “snackable” would become our pocket rituals, our chill pills. We could take out our device for 5, 10, or 15 minutes and be empowered to bring about a targeted, appreciable positive impact. The barriers to use should be minimal, the experience intrinsically rewarding – that is, it feels good to play – as well as reinforcing because it helps us meet our health goals. I think many psychologists feel that this approach is not easily conducive to a rigorous scientific approach. But if we fail to find a way to do this – good science and giving people tools they want to use – then the whole endeavor is dead in the water.

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Can Digital Mental Health Tools Save Psychology?

After decades of research on mental health treatments for conditions ranging from schizophrenia to depression, from anxiety to autism, our track record remains poor. For example, anxiety disorders alone will affect over 90 million people in the lifetime – in the U.S. alone. That’s approaching a third of our population. Yet, only a small fraction of us receive effective, long-lasting treatment. Thus, while we mental health professionals do much good and have some excellent, evidence-based treatments, we also know that, on balance, we are far from doing enough. We are failing.

I believe that there are many reasons for this failure. Psychological disorders are incredibly complex, with diverse and wide-ranging causes and manifestations that vary extremely from person to person. So we have an unbelievably tough problem to solve. But in addition, I believe that there is a two-part “recipe for disaster” that has put up additional barriers to the development of effective treatments:

1. The stigma of mental illness
2. Professionals minimize the importance of making treatments acceptable to the individual

The Stigma of Mental Illness

If you type “stigma definition” into Google, here is what comes up:

noun: stigma; plural noun: stigmata; plural noun: stigmas

1. a mark of disgrace associated with a particular circumstance, quality, or person.

“the stigma of mental disorder”

synonyms:	shame, disgrace, dishonor, ignominy, opprobrium, humiliation, (bad) reputation
antonyms:	honor, credit

It is no coincidence that mental illness is the paradigmatic example given by the dictionary. It is one of the most pervasive and persistent of the social stigmas. If we think about other sources of stigma – like the stigma suffered by those diagnosed with HIV/AIDS in the 80’s and 90’s and beyond – the stigma of mental illness is especially striking because mental illness is not contagious. But we fear it as if it were. The mentally ill are NOT more likely to commit violence, and yet, this is what many people fear. Take the media frenzy following the Sandy Hook Elementary School tragedy as an example of this type of assumption.

As long as mental illness remains a sign of disgrace and dishonor, people will avoid seeking professional help because it makes them feel broken – perhaps beyond repair.

Professionals Minimize the Importance of Making Treatments Acceptable to the Individual

There is another issue exacerbating the barrier represented by the stigma of mental illness. This barrier is that we scientists and practitioners, in our education, are socialized away from figuring out how to provide individuals with services they need in a way that they want – something that is obvious to any product- or service-oriented industry. Instead, we are taught to believe that we know best because we use the tools of science to develop the most efficacious treatments. The implicit narrative is: “We are the experts! We have figured out the best “medicine” for you, now take it!” This arrogance often keeps us from seeing that if we develop treatments that are too onerous or if treatments are embedded in a culture of disgrace and stigma, then we have failed to solve the problem. We have failed to meet “consumer needs.”

This is of course an overstatement and many mental health professionals actively fight against these attitudes. But there is a grain of truth here. Anyone on either side of the mental health fence – both professionals and patients – is familiar with this feeling, whether it’s acknowledged or swept under the rug.

How Digital Mental Health Tools Can Disrupt Stigma and Increase Acceptability of Treatments

In addition to breaking down barriers to effective, affordable, and accessible mental health treatment, I believe that digital – in particular mobile – mental health tools can be harnessed to have profound and lasting disruptive effects on the stigma of mental illness and on our failure to make acceptability of treatments a top priority. Here are five ways I believe digital mental health tools might just save Psychology:

If treatments are administered on a device, they are normalized 

If we are successful in attempts to embed evidence-based treatments into mobile and gamified formats, I believe we can profoundly reduce the experience of and appearance of stigma. Devices have become our filters of information, our gateways to the world, sources of fun, and our hubs of connection. The actions we perform on our devices, by association, feel more “normal,” more connected to every aspect of our lives and to others. This creates a process of validation rather than shaming. By putting mental health treatments on devices, we might just be normalizing these treatments and creating positive emotional contagion – treatments become “good” by association with the devices we love. And if we gamify interventions, these effects could be strengthened even further.

Self-curating our mental health

With digital mental health tools, accessibility is exponentially increased. For example, with mobile mental health apps, you have affordable help “in the palm of your hand.” This ability to curate creates a sense of empowerment. This is “self-help” in a very real sense. With this high level of accessibility and empowerment, many of us will avail ourselves of interventions to reduce negative experiences and states.  In addition, with the proliferation of digital tools to PROMOTE positive outcomes and to reach our fullest potential, we may find on the societal level that this positive focus is just as helpful – if not more so – as the focus on preventing negative outcomes. This attitude of promoting the positive is an excellent antidote to stigma. Who couldn’t benefit from promoting more of what is positive about oneself and how one lives life?

Digital health technology provides powerful platforms for community building

This is readily apparent. With greater community building comes a sense of belonging and a reduction of isolation. But digital community building also provides opportunities for effective advocacy. Of course, many such groups exist, but excellent digital mental health tools with a social media component could accelerate the creation of such systems, leveraging all the power of an individual’s full social network.

The profit motive will fuel innovation and valuing of consumer perspectives

Once interventions enter the digital and mobile technology world, the accompanying consumer focus (read $$$) will force the development of consumer-oriented products. Users have power in this domain. So, if interventions are onerous, boring, or non-intuitive, people will simply not use them. User stats will do the rest – no one will put resources into a product that people won’t use. Better ones WILL be developed.

Digital mental health increases opportunities for gamification

The gamification of mental health is beginning. At this point, we are taking baby steps, since we have an absence of a strong empirical base; in other words, there is precious little research showing that computerized games have a direct, positive influence on mental illness or on the promotion of mental wellness. But we are only in the earliest, exciting stages of this revolution. As I’ve written elsewhere, I don’t think all treatments should be computerized or gamified, nor do I think face-to-face therapy is obsolete – far from it. But I believe that if fun can be combined with powerful treatment technologies, then we can in a single step make profound progress in erasing the stigma of mental illness and creating treatments that people will truly want to use.

Mental Health on the Go

My forthcoming research paper reporting on a mobile app that gamifies an emerging treatment for anxiety and stress  – a paper that hopefully will be officially out in the next month or so – is starting to be discussed in the media, including the Huffington Post. Thank you Wray Herbert for such great coverage of the study.

 

 

My Personal Zen

To follow up on my posts about gamifying mental health, I’m excited to announce that Personal Zen, my science-based (but still fun) stress-reduction game, is ready to share with the world! It’s free in the App Store, so please download it and check it out.

Research from my lab supports its efficacy to prevent and reduce stress and anxiety. Yet, as a game, it’s a beta version and our goal is to get any and all feedback to make it more fun, user-friendly, and effective. So please try it and let me know what you think (either via this blog or the app, which has a “send feedback” button in the menu).

My larger goal is to develop a suite of mobile games for health based on sound scientific principles. As we increasingly curate our own emotional and mental wellness, I think it’s crucial that we have scientifically-supported options to chose among. Because stress reduction is key to wellness, that’s where I’m starting with Personal Zen.

Here’s how it works (as I wrote in the App Store): When we get anxious or stressed, we pay too much attention to the negatives and have less ability to see the positives in life. These habits of attention reduce our ability to cope effectively with stress and can create a vicious cycle of anxiety. Personal Zen helps to short-circuit these habits and frees you up to develop a more flexible and positive focus. You can reduce your stress and anxiety in as little as one sitting, and the more you play, the more you strengthen well-being and vaccinate yourself against the negative effects of stress.

Essentially, the app works by helping people build new habits of paying attention to the world. But building new habits takes some practice, so we recommend spending time with it every week. I love using it on the NYC subways, and it’s truly “snackable” in that using it a few minutes at a time reaps benefits.

If you’re interested in any of the scientific background on the app, I’m happy to share both specific take-home messages and data.

The Game Doesn’t Care: Why the Gamification of Mental Health Isn’t Working (Yet)

Games that are not games. There is a serious barrier to the effective gamification of mental health. This barrier is that the games we psychologists and health professionals are coming up with are not fun. In fact, they are totally uncool, border on the condescending, and wouldn’t motivate anyone to play for more than 30 seconds. This is the case even though the bar is set quite low because these “games” address things that people really want, like boosting our intelligence and memory, reducing depression and stress, quitting smoking, … fill in the blank. I’ve been fascinated with this disconnect between Psychology’s view and real-world acceptability. This disconnect is plaguing other fields as well, such as in the development of “serious games” for education. In this larger context, I’ve been working on the development of an app that takes a scientifically proven approach to reducing stress and anxiety, and embeds the “active ingredient” of this intervention into a game that is fun – fun enough, we hope, for someone to want to play for much more than 30 seconds.

Fun versus health goals. In the midst of  this ongoing development process, I had the pleasure of speaking with Nick Fortugno, co-founder of the game design company Playmatics. In addition to creating really fun games, like Diner Dash, he has created games to promote positive social change and is one of the visionary and forward-thinking advocates for the idea that serious games can and should be fun. So, he has a deep understanding of the barriers facing the gamification of mental health. As we were talking about these barriers, Nick said something that really got me thinking. He said, when we design games for education or health, we have to remember that “the game doesn’t care” about whether we’re making progress towards our goal. This elegant idea highlights the fact that a game isn’t fun because it meets some criterion we have for success – like boosting our ability to remember, reducing symptoms of anxiety, or losing 5 pounds. A game is fun because it creates an aesthetic experience and facilitates game play that we want to come back to again and again. Therefore, I would argue that a “serious” goal embedded in a truly fun game is reached almost as a by-product of the fun.

The need for backward engineering. I think I am accurate in saying that very few people, myself included, who are trying to create serious games for wellness think like this – i.e., like a game designer – about the process of gamification. From what I can tell, game designers think very deeply about the experience they want the game to promote, and then they work through the pragmatics of the game play that will facilitate this experience. This backward engineering from the point of view of the aesthetic/experiential goal to the pragmatics of the game is the opposite of what psychologists do when they think about gamification. Instead, we have parallel streams of development in which (a) we know that our “game” (read scientific protocol) is truly boring, and (b) we have to somehow decrease the snore factor. We think: “Hm, here is my very rigid experimental protocol/computerized intervention. I must overlay this protocol with some cute little animated guys, perhaps with a fun back-story (wizards? aliens?) and then make sure users get points when they conform to the requirements of the protocol.” Sounds thrilling, huh? So fun? Exactly the recipe for the next Dots? Right…. So, we have a lot to learn from game designers, and I believe that crucial to the future of the endeavor of gamifying mental health is partnering with people who know how to create fun and understand the process of game design.

Pocket rituals. What would it be like if we created mental wellness tools, or even interventions for serious mental health problems, that were truly fun and that could become part of our array of habits and strategies for feeling better, reducing symptoms, performing more efficiently, or dealing with stress?  These games, if “snackable” would become our pocket rituals, our chill pills. We could take out our device for 5, 10, or 15 minutes and be empowered to bring about a targeted, appreciable positive impact. The barriers to use should be minimal, the experience intrinsically rewarding – that is, it feels good to play – as well as reinforcing because it helps us meet our health goals. I think many psychologists feel that this approach is not easily conducive to a rigorous scientific approach. But if we fail to find a way to do this – good science and giving people tools they want to use – then the whole endeavor is dead in the water.