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. boring gameI’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.

Calming the Politics of Fear: Technology and the Anxious Brain

“Calming the Politics of Fear: Technology and the Anxious Brain” is my talk from Personal Democracy Forum 2016 (June 10, 2016), adapted here for a written format. This talk was part of a set of talks entitled “Tools We Need.” I argue that using technology in the service of health is a very sharp, double-edged sword, and that we must reclaim technology culture to serve and amplify humanity and well-being, rather than serve the digital economy. The video of the talk is available here.

Threat Bias

I became a psychologist and a researcher because I wanted to help people overcome problems like anxiety and depression. But I quickly discovered that no one likes you when you are a mental health professional. Psychologists pry into people’s minds and tell you it’s your mother’s fault. Psychiatrists prescribe you drugs with terrible side effects and that emotionally numb you. It’s no coincidence that Hannibal Lector is a psychiatrist.

And that’s when I got it. We psychologists and psychiatrists have profoundly failed people. We have failed to give people the treatments they need – and instead give people treatments that are too expensive, too time consuming, too hard to access, and perhaps most importantly, deeply stigmatizing. Largely because of us, people fear that their hearts and minds will never heal and that they will continue to feel broken inside.

I believe that digital technology can offer us some unique ways out of this mess, and provide tools for both professionals and each of us as individuals to heal problems like anxiety and depression.

But I also believe that using technology in the service of health is a very sharp, double-edged sword, with high potential costs as well as benefits.

In my research lab, we study things called cognitive biases – invisible habits of thinking and paying attention that intensify and even cause anxiety, depression, and addiction. I’ve translated this research into digital techniques that are designed to short circuit cognitive biases.

Let me explain cognitive biases by conducting a little experiment. Please fix your eyes on the screen. [[The following picture flashed up on the screen for 2 seconds]]

angry face

How many of you saw the angry face? How many didn’t? The results of our experiment?: Decades of research tell us that people who tend to be anxious or stressed detect that angry face more quickly, and pay attention to it longer and intensely than people who are relatively less anxious and stressed.

This preference to pay attention to and prioritize the negative is called the threat bias.  And here’s the kicker. The threat bias piggybacks on one of the triumphs of evolution – the ability to quickly and automatically notice danger, which in turn triggers us to fight or take flight to deal with the danger.

But the threat bias highjacks and skews this evolutionary advantage. It acts as an unconscious information filter, an imbalance in what we pay attention to that makes us actually prefer and prioritize threat and negativity at the expense of the positive. When the threat bias becomes a rigid habit of looking at the world, it puts our fight/flight response on a hair trigger, and sky-rockets our feelings of stress and anxiety – We see monsters in the closet even when they’re not there.

For example, imagine you’re giving a talk, like I am now, and there is a smart audience in front of you, bright lights beaming down. If I had an amped-up threat bias, I would very quickly and intensely notice that there is this one person in the audience who is frowning, shaking his or her head, maybe falling asleep. I will fail to notice all the interested and smiling faces in the audience, and get stuck on this person. The natural result – I feel more anxious and stressed, I am on the look-out for further negative information, and I ignore positive evidence that I’m doing a good job.

In this way, the threat bias drives the vicious cycle of stress and anxiety, takes up mental bandwidth, and puts us at a disadvantage when there is no real danger to face, when the monsters in the closet are only in our mind.

Personal Zen

Now, this threat bias doesn’t sound so great. Not great at all. But I love the threat bias and other cognitive biases. That is because there is an empowering message hidden in the idea of cognitive biases. Biases are essentially habits. When we have a bad habit, we are not broken inside – to change, we just need to learn a new habit.

So I have spent a good part of my 20-year career studying how we can derail cognitive biases like the threat bias, learn new habits to heal the anxious brain, and translate these techniques into a digital format.

Over these 20 years as a researcher, I’ve done all the things that a researcher is supposed to do, and enjoyed the process: received grants, run dozens of studies, published over fifty scientific papers on everything from the emotional lives of children to the neuroscience of the anxious brain, became a full, tenured professor at the City University of New York, where I founded the Emotion Regulation Lab, The Center for Stress, Anxiety and Resilience, and the Center for Health Technology and Wellness.

But I only really began to make progress and question how my research on cognitive biases was making a difference when I was pregnant with my daughter. I was talking to my husband about how I felt stuck, and that maternity leave was going to be my chance to think outside the box and he says, “Why don’t you build an app for that?” An app, I said – that’s ridiculous. There are too many “apps for that,” ugh.

But, he got me thinking that maybe this really was a way to do things differently.

Enter attention bias modification, a technique I study in my lab and that takes the threat bias and turns it on its head. Attention bias modification sounds a little like this:

clockwork orange

But I promise you, it’s not. Attention bias modification uses simple computerized techniques to rebalance the scales of attention to create a new habit of preferring and prioritizing the positive over the negative. It is perfectly suited to digital and mobile technology because it’s brief, cheap & easily accessible, and doesn’t require a shrink.

I’ve created an app called Personal Zen that embeds these techniques into an engaging, on-the-go format. Here is how it works – We see both an angry and pleasant sprite quickly pop up in a field of grass. The sprites then burrow down into the field, but only the pleasant sprite leaves a trail of grass. Our task is to trace that windy trail. Because the angry and pleasant sprite appear at exactly the same time, our brain is forced to figure out what to pay attention to. By ALWAYS following the trail of the pleasant sprite, our brains learn to automatically focus on the positive and disengage from the negative. We start building a new habit of attention. Follow the joy.

Picture1

It’s deceptively simplistic, but clinical trials show that using Personal Zen and the attention bias modification techniques it is based on effectively rewires our brains to disengage from the negative and focus more on the positive – and this translates into reducing stress and anxiety after as little as single use of the app.

The Politics of Technology and Fear

So Personal Zen is a technology-based way to help heal the anxious brain. Yet, I simultaneously believe that the digital technology culture as it stands now is also one of the most surefire ways to amp UP the threat bias and make our anxious brains worse.

We mediate our lives through mobile and digital technology – we know this, it’s how we filter the tremendous complexity of our lives. But we are living in an attention economy in which news organizations, businesses, and our social networks are constantly pinging, ringing, and texting us, competing for our rapidly dwindling bandwidth of attention. We are on a digital mental treadmill. Corporations spend millions figuring out how to best keep us on that treadmill by high jacking and seducing our emotional brains, how to reward us, titillate us, and scare us into looking, clicking, buying, eyeballs on the screen, and how to mine, use, and sell our personal data.

The politics of fear are finding fertile soil in this attention economy, with fear-mongering politicians using these same techniques to drive opinion and votes, to amp up our anxieties and fears. The only good voter is an anxious voter.

The digital mental health field as it stands is not much better. There are thousands of mental health apps on the market, but fewer than 1% have ANY scientific evidence base. So, it’s essentially the Wild West, full of snake oil salesmen. This is tough on us consumers. How do we find the signal in the noise? The FTC’s crackdown on digital brain training companies like Lumosity, which was fined millions for unfounded medical claims, is a sign of the times.

The Future is Now

But let’s turn to the future.

It is crucial that at this key moment in time, we envision a new and revolutionary future for the role of technology in health. That future has to be now, and we have no time to waste. The digital technology culture in which health care is evolving is consciously and relentlessly designed to brain hack, co-opting our anxious brains, our addicted brains, our bored and restless brains. We have to disrupt the digital disruption of our lives.

Don’t get me wrong, the human race has been brain hacking for millennia, shaping and mediating how we view and make sense of reality – through language, religion, the arts, politics, education…. Along come radical advances in digital computing and now we have another tool – but it is a tool that should NOT be privileged above others. And we must take a cold, hard look at how in some contexts, the costs of these digital tools outweigh the benefits, leading to information overload, greater anxiety, and social disconnection.

So I say, let’s step off the digital mental treadmill. We all know ways to do this, ways as simple as silencing the endless rings and buzzes of our notifications, turning off our devices during meals with our family and friends, and minimizing the time as family, parents, and friends, our loved ones see the back of our devices rather than our faces. When we take these steps, we treat our attention as sacred and precious, as a resource to be spent wisely. These values must be front and center when we design and use health technology.

I challenge all of us today to reclaim technology to heal the anxious brain and heal the culture of fear: Designers, help us streamline screen time – less time with eyeballs on the screen – and design technology that facilitate our ability to live truly connected and fulfilling lives; Consumers, demand digital health tools with scientific backing and be conscious of how you’re spending your precious, precious attention; Politicians, draw on the best rather than the worst aspects of the attention economy. The only good voter is an informed voter. If we do these things, together, we will create the tools we need.

Why Digital Mental Health is Like the Wild West

Why Digital Mental Health is Like the Wild West

When I talk to people about the digital health space – specifically digital mental health – I often say, “It’s the Wild West!” and everyone nods. But then I stopped to think about what I really mean by the Wild West. I realize that the metaphor holds up very well.

wild west

There is a gold rush. The California Gold Rush began on January 24, 1848. News of the gold brought some 300,000 people to California from around the world. They were called forty-niners in reference to the year the fever really hit, 1949. Tens of billions of today’s dollars in gold was recovered. The gold rush transformed the economy of California and economies all over the world.

The financial opportunity – and temptation – represented by the digital mental health revolution is similarly profound. Americans alone spend over $148 billion annually on mental and emotional health. Moreover, more than half of people suffering from emotional and mental distress will never seek treatment – meaning there is a huge, unmet need. Of these who don’t seek treatment, over 45% cite price as a barrier, and over 40% cite stigma as a barrier. Digital health tools, like mental health apps, address these barriers by being highly accessible and highly affordable. They also have the potential to neutralize stigma because, as I’ve argued before, mobile devices are the hub of our lives and thus what we do on them automatically gains an aura of “good.”  Digital health therefore represents a perfect marriage between social good and economic potential, and there are plenty of forty-niners who see this opportunity and want to cash in.

There are snake oil salesmen. Indeed, many companies are jumping on the wagon and digging for digital health gold (to keep the Wild West metaphor going). Some of these companies offer great, beneficial products, but others are “snake oil salesman.” Snake oil is an old-fashioned term that tends to refer to fraudulent health products or unproven medicine, but in general refers to any product of questionable quality. A snake oil salesman is someone who knowingly sells these fraudulent products. You see these guys as comic relief in Western movies all the time, usually a traveling “doctor” selling fake medicines, who leaves town before customers realize they have been cheated.

One way for us to get around the risk of snake oil is to elevate the dialog around digital health and develop ways of evaluating the scientific quality of what’s out there, since none of this is regulated (yet). This will help us look past the shiny bottles of alluring medicines that are actually snake oil, and find the real healing agents. Psyberguide is one organization I came across that appears to be trying to do just that.  If we don’t push ourselves as an industry to meet standards, we risk becoming comic relief rather than a true paradigm shift. We also risk repeating the failures of the analog healthcare system, just making them digital.

There are pioneers.  I believe that a science-backed digital health revolution will be the single most important paradigm shift in the failing mental health industry. This revolution will allow people to promote their personal wellness like they do their physical wellness and fitness. It will allow people to access treatments that are effective without being too expensive, burdensome, or stigmatizing. We need to think outside of the box for a true paradigm shift to occur in how people access support for their emotional and mental health – whether that’s the transformation of how patients access their health information through electronic medical records, how health information is collated to lead to better diagnosis and treatment, how health information is gathered through tests done on mobile devices, or how interventions are accessed, through mobile health apps and digital brain training. Pioneers in digital health are rethinking how to empower the individual to promote their own mental and emotional wellness, to use personal health information to actually improve our lives, not just be monetized by big companies mining our big data.

I firmly believe that destigmatizing mental illness and emotional distress will be the linchpin in this paradigm shift. Mental health – when we say those words, we think illness, not health. We think of people being crazy, despondent.  Why is that? It is because Psychology and Psychiatry have failed to make mental health a positive goal like physical health and fitness. When we struggle emotionally, we feel broken. Treatments are burdensome, hard to access, and stigmatizing. We need to be on the vanguard of a paradigm shift away from stigmatizing, expensive treatments emerging from the “if we build it they will come” mentality, and towards a new vision in which people are empowered to personalize their mental wellness through tools that work for them, when and where they want them.

If pioneers brave the Wild West that is the digital health field of 2015, we have a chance of creating something that transcends our humble beginnings to actually make a difference.

The Future of Medicine is in Your Smartphone

Picture by Helen Weinstein

A great essay from the Wall Street Journal on the promise and challenges of the smartphone revolution in healthcare – from mobile physical exams, to merging day-to-day health data from wearables with medical records. A key – and underdeveloped – innovation here will be to integrate health tracking with mobile therapies. This transformation of healthcare – both physical and mental – is going to happen, and it is up to us, as patients and professionals, to make sure that it is done right, with the privacy and well-being of the individual as top priorities.

I’ve been interested in some emerging companies, like Mana Health, that are on the cutting edge of this revolution because they are solving the problem of how to effectively merge clinical data with health data collected in the daily lives of patients, and directly empowering patients to have a clear voice in their healthcare and greater collaboration with doctors.

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

iPhone Screenshot 1

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. boring gameI’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.