Gamification and the Psychology of Game Design in Transforming Mental Health Care

Researchers and health professionals have long been curious about the potential of electronic games for purposes beyond entertainment. This topic is of particular importance given the rapid growth of the game industry, whose products are enjoyed by over 1.5 billion people worldwide (EEDAR, 2015), many of them on mobile devices. As the number of smartphone users continues to grow, with conservative estimates projecting a rise from 2 billion worldwide at the end of 2015 to 6.1 billion in 2020 (Ericsson, 2015), the mobile games market is likely to keep pace. By 2020, 4.5 billion people, nearly half the world’s population, will be gamers. As such, there have been a number of efforts to leverage game-related techniques and technologies for positive impact, mostly through gamification and serious games. Most, however, have been met with limited success.

Gamification is traditionally defined as the addition of game mechanics to everyday processes (Huotari & Hamari, 2012). In an attempt to increase motivation for otherwise unpleasant tasks, it is currently one of the leading buzzwords in the health care sector. Like big data, it was positioned as a magic bullet that would combat lack of adherence to medications, encourage healthy eating and exercise habits, and otherwise help people manage their conditions. The reality falls short of the hype, with 80% of all gamification initiatives failing to meet their objectives, especially as they pertain to long-term change (Gartner, Inc., 2012).

Serious games, a somewhat oxymoronic term deriving from the Renaissance serio ludere, refers to entertainment that dealt with serious matters (Djaouti, Alvarez, Jessel, & Rampnoux, 2011). These are games that have something other than “entertainment, enjoyment or fun as their primary purpose” (Michael & Chen, 2005). They long predate the concept of gamification and, indeed, account for some of the earliest games, predating even Pong (Djaouti et al., 2011). However, despite their long and storied history, most of these games have never been commercially successful. SPARX, an award-winning game developed as a self-help intervention for adolescents with mild to moderate depression, is a good example of this (Metia Interactive, 2011). In clinical trials, it was shown to be more effective than treatment by trained counselors, with 44% of those who played the game achieving remission from depression, as opposed to the 26% in usual care (Merry et al., 2012). However, its clinical efficacy—and its many awards for innovation—did not translate to commercial success, with Linkedwellness, the startup that published SPARX in North America, shutting down in 2015. SPARX’s lack of widespread appeal is not atypical of serious games, which are often effective in accomplishing limited clinical or learning goals but fail to gain much traction outside the clinical or classroom environment.

The obvious question of why these game-based interventions, while initially promising, fail to achieve wider success has an equally obvious answer: bad design (Gartner, Inc., 2012). This is not by intention, but by oversight, as health care professionals that work with developers often lack an understanding of the principles of design and how to clearly communicate their vision with their team and with the general public. SPARX is an excellent example, with its problematic branding as a game for depression, made obvious by the inclusion of PHQ-9 (Patient Health Questionnaire) before every play session and references to enemies as GNATs (Gloomy Negative Automatic Thoughts), compounded by the poor quality of the version Linkedwellness released for mobile devices (Merry et al., 2012). This meant that potential users were not only turned off by the stigma around mental illness but also by an unusable user interface, a weak storyline, and a game that was simply not much fun.

To better leverage the potential of games and game-based techniques, we must take a more holistic approach, examining how clinical knowledge can be applied to work in conjunction with the principles of design, in crafting engaging, immersive experiences with the power to heal. As it turns out, the two need not conflict, as the core of game design is largely informed by—or at least draws from the psychological principles described in self-determination theory (Deci & Ryan, 2000), salutogenesis (Antonovsky, 1987), and well-being theory (Seligman, 2011). Of course, there are other influences as well, such as the notion of a game occurring within a “magic circle” isolated from the outside world, within which different rules apply (Huizinga, 1938), with the work of Edward Castronova (2008), a pioneer in the study of what he coined “synthetic worlds,” suggesting that this circle was “porous.” That is, behavioral assumptions, attitudes, and other elements from one side of the membrane can and do cross over to the other. Games can thus be understood as part of a larger system, with people engaging with games as much as they do with things in the physical world.

It is no accident that meaningful choice is a central tenet in game design, nor that people forced to play against their will both enjoy a game less and gain less benefit from it (Heeter, Lee, Magerko, & Medler, 2011). After all, player engagement can be explained by a motivational model derived from self-determination theory, which stipulates that one’s satisfaction, immersion, and enjoyment of a game are mediated by how that game fulfills the psychological needs of autonomy, competence, and relatedness (Przybylski, Rigby, & Ryan, 2010). The relationship between challenge, enjoyment, and performance is greatly tied to how “coherent” the experience is (Antonovsky, 1987), much as stipulated in the salutogenic approach, which looks at health and well-being as a continuum (as opposed to the medical model’s health vs. illness dichotomy). In this model, the key factors behind coherence are comprehensibility, manageability, and meaningfulness, which in game design map to a player’s ability to understand the game world, to meet the challenges the world imposes on them, and to feel that these challenges are worthy of investment and engagement. When all these factors are in place, and when an experience is both engaging and coherent, what results is “Flow” (Csikszentmihalyi, 1990), or a state of energized focus, full involvement, and enjoyment that characterizes the best commercial games, such as Halo, Journey, or The Sims, but is conspicuously absent in most serious games.

In the past two decades, however, as games increasingly become connected experiences, with people from around the world coming together to compete, cooperate, and otherwise participate in virtual worlds, the design of social systems and how humans interact with each other has become more important than ever. Previously, a successful game simply had to provide enjoyment, engagement, meaning, and achievement to its players. With online games, how people interact and the relationships they have with one another becomes more central with player retention modeled by how well a game satisfies all these needs, and community health modeled by Seligman’s (2011) well-being theory.

As a researcher, the author’s current area of focus examines the impact of social system design on the growth and characterization of online communities and on player well-being, filling in a crucial gap of understanding in this ever-evolving space with a goal of promoting engagement and positive impact, while minimizing the potential for harm. In this connected age, there is a need for game designers to understand the underlying psychology behind their work, just as there is a need for health care professionals and others who seek to tap into the potential of games to understand the value of design in remediating therapeutic interventions into a new medium.

Games have an enormous potential to transform the future of care in mental health, public health, and more. To tap this potential requires respect for games as engaging, compelling experiences, as games are most powerful as tools for learning and behavior change when people choose to play them, without focusing solely on their educational or therapeutic elements. It is no accident that the central tenets of game design so neatly parallel those of human motivation, engagement, and well-being, because a well-designed game is not just entertainment but a synthetic world. This context potentially allows for satisfaction, achievement, meaning, education, therapy, and more.