5 Lessons In Gamifying Mental Health
Responsibly, ethically, and effectively
I don’t normally hit the breaks this hard at the very start of an article, but I think a lot of people reading this might have a sharp, instinctive reaction to the headline of this piece. Gamification can be manipulative and dark and deals with internal forces that are hard for even PhD therapists to fully understand. We are in the middle of a mental health crisis right now, and many rightly fear that more technology, more apps, more screen time, more games, could be like trying to fight a fire with gasoline.
The truth is, gamification is an extremely powerful tool in the therapeutic tool kit, both as an engagement mechanism and as a therapy in and of itself! Apps like Calm and Headspace have been doing it for many years.
However, many are rightly suspicious of gamification… and I’m one of them.
I think this is important, because if we don’t talk about design’s power to manipulate and compel, we risk doing serious harm to people, not to mention counter our own business goals.
Nearly all of my clients in the past three years have been interested in mental health in one way or another, most of them designing specifically for it. In that time, I’ve come to discover much about the intersection of games and wellbeing.
Here are five of the most important lessons I’ve learned.
1. The Chocolate Was Good For You All Along
Many people talk about applied game design as “chocolate covered broccoli.” You disguise the healthy thing as an enjoyable thing, and people won’t mind doing it.
This is especially associated with learning games for kids. “What if kids could learn civics without even knowing they are learning? Wow!”
This characterization makes a number of mistakes, but the most serious of them is assuming that games (the chocolate in this scenario) are bad for you without the learning content (the broccoli).
For decades, concerned people (primarily those that do not play games) have assumed that video games are a social ill and strived to prove they cause all kinds of problems. Obesity, alienation, violence, anti-social behaviors, stunted development, racist and sexist views, addiction, mass shootings, and even extremist ideologies have all been laid at the feet of video games.
In truth, there is virtually no solid evidence that game play, even of so-called violent games, causes any of these issues.
Quite the contrary, the vast majority of gamers tell researchers that games improve their mental health. Games help people unwind, reflect, decompress, socialize, and understand the world.
This isn’t to say that no game is problematic. In fact, we know that games that use dark patterns (addicting mechanisms, random intermittent feedback, poorly moderated community spaces, etc.) can be quite harmful. These design patterns are intended to make the developers as rich as possible without considering the consequences to the player.
But gameplay itself, without these tactics, is actually quite good for us. They were good for us all along.
It’s like when we discovered that dark chocolate (the kind without much sugar) is actually good for our hearts. The chocolate is like play: enjoyable and beneficial. It’s the bad stuff people add to make it sell better that hurts people.
2. Demographics Matter (A Lot)
One problem designers, especially gamification designers, make is assuming fun is fun and people are people. When you look into it, you discover the kinds of game mechanics that appeal to men are quite different than those for women. Older players prefer different games than younger ones. And people who live in affluent cities have very different play preferences than those who live in rural communities in the global south!
It’s important to do the UX research work to understand your user well. This is even more important when it comes to mental health.
The starkest difference I’ve seen is in how men and women view their mental health. Both men and women prioritize this, but approach it in different ways.
Women in affluent countries think of their mental health kind of like tending to a garden. They are looking for good practices they can do to keep that garden growing and healthy, or when they notice problems (an errant weed or a wilting tomato plant), are eager to attend to them with specific solutions.
Their main issue is knowing exactly what to do, and finding the time to do it.
Designing for this demographic is about making things quick, simple, and pleasant while taking out guess work.
Men in the same communities exhibit completely different beliefs and needs. They are likely to have neglected mental health issues until they have become a serious problem, and are not used to being cared for in this way.
In fact, they may not even understand that they have a problem, having been habituated into thinking stress, isolation, and even depression are normal.
When a solution is presented, they will frequently show skepticism toward it. Mental health apps for men, therefore, should try to articulate a specific problem rather than use buzz words like “wellbeing” and “mindfulness,” and take a problem/solution mindset. They want to deal with problems themselves, and should be made to feel as though this is what they are doing.
Most men also have a different relationship to games and gaming than most women, and are more likely to use games as a form of self-medication already. Find out what your customers play and leverage that to help them in a more methodical way.
These dichotomies exist across many backgrounds, not just gender. Rural Christians in the U.S. may be skeptical of meditation and yoga, being ideas associated with Eastern religion. Meanwhile teens have entirely different preferences than adult designers might expect. Hint: they’re private people who desire inner quiet and reflection more than constant sharing of every aspect of their life.
The social-sharing lessons from my previous piece on this topic broadly apply, even to the most hyper-online Zoomer.
3. Deliver Instant Feedback
Part of what makes a game so powerful is instant feedback. In his famous treatise “Flow: The Psychology Of Optimal Experience,” psychologist Mihaly Csikszentmihalyi talks about clear feedback being an essential ingredient for entering the flow state. This is when time slips away and we feel totally focused and exhilarated.
Many activities can give us this, but games excel at it for their strong goals and feedback mechanisms. This makes them an ideal delivery system for mental health interventions, not least of which because they actually do make us feel better when we are stressed!
This becomes especially powerful when combined with other therapies known to instantly improve mood and experience: meditation, gratitude reflections, and diaphragmatic feedback to name a few.
Use gamification techniques alongside proven therapies to double their effect. Or, use feedback mechanisms to make long-term, difficult practices more rewarding in the short term.
4. Right Game, Right Player
I wrote above about how different demographics have different needs both in terms of their understanding of mental health and the types of games they prefer. In fact, it goes even deeper than that.
Many who try to create mental health interventions using games try to filter out everything they think is “bad” about games (violence, stress, depictions of firearms) and replace them with more palatable content (gardening, cooking, healing, hugs).
For some people, this is exactly right. These gamers enjoy so-called “cozy games.” This genre, growing daily, includes a lot of wonderful experiences designed to lower stress and capture the player in a world that feels like a hug. This isn’t to say that a cozy game cannot challenge us. But the pace is slower and the images and sounds are gentler. The rough edges are all sanded down.
However, this doesn’t mean that cozy games are the best for everybody. In one study, players of “Super Mario Odyssey” (a 3d action platformer) saw their depression symptoms improve significantly more than those that received therapy… and even more than those who got actual medication.
Other players report lowered stress after playing 3d shooters. In fact, first-person shooters are the most beneficial genre of game for regulating mental health and stress. The mechanism of this has to do with stimulation of the vegus nerve, a proven medical therapy outside of games.
Companies such as Deepwell DTx are currently working to develop games that deliver these therapies in a predictable way.
That said, many patients will not prefer these games, so it is important to understand these preferences in your design.
5. People Open Up To Chatbots
One of the very first chatbots was a program called Eliza, a simulation of a Rogerian psychologist. Eliza wasn’t very sophisticated, and mostly repeated phrases back to its users, formatted as questions.
Yet, Joseph Weizenbaum, Eliza’s creator, reported finding one of his employees chatting with Eliza in his office late at night. She’d broken in to talk with this AI “therapist.”
Cut to sixty years later.
Virtually every tech startup in 2024 is leveraging generative AI such as LLMs. These programs are infinitely more sophisticated and powerful than Eliza, and unsurprisingly they’re beginning to finish the job it started.
Many might read this with skepticism. Could a machine ever really replace human therapists?
The answer is probably not. Except, an AI therapist is infinitely more accessible and cost effective.
Not only that, but there are people out there who will talk to an AI chatbot, but are afraid to talk to human beings about their problems.
Every bit of evidence I have seen shows that users of all types are willing to pour their guts out to a chatbot, and do so eagerly. It’s like singing in the shower vs. singing on stage.
The implications of this are huge, and not just because there is a high potential for monetization. The bigger implication is on the unpredictable follow-on effects of a society engaged with AI therapists around the clock.
How can gamification help?
The obvious answer is to make sure people are using their therapies, coping techniques, and so on and not just gibbering to a chatbot about their feelings all day.
Using game mechanics to encourage and structure therapeutic paths could be the best way we have to keep patients on track.
Gamification might also be necessary to enforcing limits and providing guard rails. “You’ve reached your goal for the day” is an elegant way of saying, “hang it up, pal.”
Lastly, chatbots are playful, almost definitionally. The bot prompts you. You reply. It takes your feedback and transforms it into a new prompt. It’s game-like, almost as if you’re tossing a ball back and forth. It encompasses language, rules, goals, feedback, curiosity and exploration, and a low-stakes environment that typifies game play. In fact, with the right attitude, chatbot use is a game.
Therefore, it is important to approach it as such. Otherwise, we risk misunderstanding the behaviors these LLM therapies will create.
Putting Out The Fire With Gasoline
These new kinds of games are on the way. In fact, they’re already here.
In the past few years, a flood has begun of digital solutions for physical problems: Wellness apps, DTx (digital therapeutics), software as a medical device, all of this is basically a way of saying an app is medicine. Just like any treatment, a digital one won’t work if the patient won’t take it. And to make sure the patient takes it, developers are incorporating engagement techniques including gamification.
All this is not to simply say “it’s coming, so get used to it.” Rather, I mean to say “it’s coming, so get ready for it.”
Most people intuitively understand the power of gamification, even when they suspect it to be generally malevolent. Others, techo-utopiasts who believe that technology is only a positive thing, and will deliver us from all of our problems, even ones we create, will seek to crank the engagement mechanisms in their products to the max, come what may.
One of my highest ideals is to design nothing that violates my own values.
The truth is, gamification is neither inherently good or bad. But we must understand and talk about how it can do harm in order to design implementations we can be confident will help.
Sam Liberty is a gamification expert, serious game designer, and consultant. He teaches game design at Northeastern University. He is the former Lead Game Designer at Sidekick Health.
