To Gamify or Not to Gamify Behavioral Health Care

by Lisa Henderson, Synchronous Health Co-Founder & COO

This weekend I was on a short road trip, just three hours each way. I often listen to an audiobook or podcasts while I’m in the car for an extended period of time. So as I queued up my podcasts, I was out of the standards. I’m caught up on both Hidden Brain and Freakonomics. I did discover T.I.’s expidiTIously, which was really interesting with a very different point of view from the psychologists and economists featured on my two go-to podcasts. That episode, T.I.’s first, hit #1 on Apple Podcasts (NSFW).

I had about another hour in the car and was in need of another podcast and decided to take a listen to the TED Radio Hour’s Press Play episode. I was hesitant to listen to this podcast. It’s a debate we’ve had internally at Synchronous Health many times and externally with various customers and investors. Here are a few of the points of discussion we’ve had about the role of gamification in our programs:

It’s unclear how much they help.1

Theoretically, gamification is a great idea. But we just don't have evidence that it lives up to its potential in the treatment of behavioral health conditions. Here's the rationale for all the ways it could get people engaged in therapy that will change their lives.

You’re willing to try it. People are more likely to try behavioral health programs if they are presented as games rather than as treatment. Think of your daily gummy multivitamins and how much more likely you are to take those as opposed to going to the doctor once a day for a shot of vitamins. Your gummy vitamins are like a treat. And at the same time, it can’t be condescending or have a hidden agenda. Nobody likes to be talked down to or tricked. Even my gummy multi-vitamins are the ones for adults. I leave the cartoon gummies for my nieces and nephews.

You’ll use it consistently. Once you start the game, you’re much more likely to get engaged in it if it’s something you can win. Winning traditional therapy is much less exciting (for most people – I personally really like winning at therapy). The constant feedback and clear accumulation of rewards signals that you’re doing this right. In traditional therapy, winning can be counterintuitive. You win when you confront your therapist, if part of your symptoms is passivity, or you win when you finally tell the whole truth about an event if you’ve been hiding it your entire life. It’s not as clear and doesn’t feel as good as collecting the coins and powering up that games offer.

It actually achieves the goals of therapy: to change your thoughts, feelings, and behaviors. At the end of the game, are you actually better? How long will you stay better? Do you need to play the game again? Do you now need to play a different game to change a different but correlated problem in your life?

It is clear that sometimes they can hurt.

Is the game a safe environment? The most successful games are ones that have a social component to them. A recent New York Times article begs the question: Are Video Games the New Social Network? The opinion piece points out that new games being developed often include a social component because players demand them. While some players criticize multi-players games for taking shortcuts in character development and rich backstories (presumably to be filled in by the players), most players enjoy games with friends and strangers, preferring the social interaction. Where this becomes a problem in behavioral health care is in the misalignment of the social interaction with the goals of the players. Players in early recovery are easily accessed by people who are looking to capitalize on their cravings and urges to continue use, turning the game into a marketplace. Players in treatment for relationship trauma can be easily found by bad actors who are looking for their next target. These examples more nefarious than the interactions typically are, but they highlight the point that vulnerable people are easily found by people who do not share the same goals – or at the very least don’t share the same commitment to their shared goal. I have seen over and over again where two people in recovery (from anything) meet and as one starts to struggle the other tries to help, resulting in both of them going down, returning to their illnesses.

You could be replacing one addiction with another. In 2018, the World Health Organization added gaming disorder to its list of diseases and disorders, the International Classification of Disease. We may also see it added to the Diagnostic and Statistical Manual in its next release. Similar standards of diagnosis apply to gaming disorder as to any other addiction. The activity must result in impairments in personal, family, social, occupational, or other important areas of functioning for at least 12 months. Whether we’re talking about nailing a project at work, winning a video game, or taking cocaine we’re talking about the release of dopamine and other neurotransmitters responsible for how we feel. Researchers found that the brains of people addicted to video games looked similar to the brains of those addicted to drugs.2 It also found that brain development and presence of other conditions, such as ADHD or Depression, might increase someone’s susceptibility to gaming addiction. We’ve long understood the correlation, not causation, of these conditions and addiction.

People don’t actually get into the good-for-you games as much as they do the just-for-fun games. Many games that are built for improving behavioral health are built by psychologists or counselors rather than by expert game designers. I can admit there would be a very big difference between the experience of a game I built and a game that Tim Sweeney built. If we really want to get adoption of gamified behavioral health improvement programs, we are going to have to treat the programs with the same amount of respect and attention we treat commercial games, with a foundation in efficacy and science as dictated by any good mental health program, but also with user-centered design, collaborative development with a team of people who understand both the behavioral health aspects of the game and game designers and developers who understand how to design a game for adoption. Perhaps most importantly, rapid iteration to test and refine the game to optimize engagement and improvement.3

So what did I learn after listening to this podcast? Most importantly I learned that there is good work to be done to help people heal from behavioral health conditions and that gamification can and should be part of it. I also learned that all the debate we’ve had in the office is right on target. We need to be asking ourselves these questions and be sure that we have solid answers before pursuing a gamified route. There is plenty of science available to guide the development of effective and ethical gamified behavioral health programs. The word of caution is that most existing programs probably don’t meet the standards that should be applied. We need good answers to the original questions:

  1. Are we sure it helps?
  2. Is the program designed and built in a way that respects the player and what he/she is overcoming?
  3. Are we sure it doesn’t hurt? And how will we catch people and support them if we see things going sideways?
  4. Is it fun?
  5. Is it social? Is it safe?
  6. Do players get better and achieve their goals?

References

  1. Fleming, T. M., Bavin, L., Stasiak, K., Hermansson-Webb, E., Merry, S. N., Cheek, C., … Hetrick, S. (2017). Serious Games and Gamification for Mental Health: Current Status and Promising Directions. Frontiers in psychiatry, 7, 215. doi:10.3389/fpsyt.2016.00215
  2. Weinstein A. M. (2017). An Update Overview on Brain Imaging Studies of Internet Gaming Disorder. Frontiers in psychiatry, 8, 185. doi:10.3389/fpsyt.2017.00185
  3. Fleming, T. M., de Beurs, D., Khazaal, Y., Gaggioli, A., Riva, G., Botella, C., … Riper, H. (2016). Maximizing the Impact of e-Therapy and Serious Gaming: Time for a Paradigm Shift. Frontiers in psychiatry, 7, 65. doi:10.3389/fpsyt.2016.00065