How Video Games Can Help with Therapy

Whether it’s being blamed for real-life atrocities or the cause of an impossible number of addictions, video games continue to get a bad rap in the modern day. My website has tried to spotlight the good that video games are capable of, such as helping with everyday anxiety and even helping with stroke rehabilitation. While sharing this information with the world, there is always one topic that I wanted to explore further – can video games help those with diagnosed mental health conditions? How has the mental health system taken advantage of such an interactive medium to try to improve mental wellbeing in therapy?

I knew this would be a very deep research dive, and my Patrons were kind enough to allow me to focus on this topic for a few months. Armed with over 100 sources, I am delighted to take you all on a journey on how video games can help with mental health therapy.

As a very important disclaimer, I need to emphasise that this article does not condone or endorse self-medication with video games. This article contains information on games that were specifically designed to help with a mental health condition, or commercial video games monitored by a trained mental health professional and/or academic. Please seek help if you are experiencing mental health difficulties, do not attempt to self-medicate with video games.

As usual, there will be a summary at the bottom if you do not wish to read everything. Now, let’s begin!

Background

Before we dive in to the practical applications of video games, I would like to explore why video games were even considered as a means of mental health therapy. On the surface, it can seem almost disrespectful that an entertainment platform would be selected to help with serious mental health conditions. So what brought us to this point?

First of all, it’s important to consider the current climate we’re in. Over 10% of the world’s population is affected by mental health conditions [1], leading to overburdened and underfunded mental health systems. For example, 35% of Americans in 2017 with a major depressive episode did not receive treatment, and those who try to seek help can wait for years before receiving an appointment, if they even receive one [2-3]. If you wish to seek help for mental health difficulties, you must also consider the potential financial cost: the monthly costs of mental health treatment can range from $370 per month in the US to up to $340 per month in Europe [4-5]. The burden of mental health care has only increased with the COVID-19 pandemic due to ever-increasing backlogs and the need to explore alternative methods of care delivery for vulnerable people [6-7].

Large backlogs, healthcare costs, and difficulties with face-to-face treatment have prompted calls to take advantage of the technology-rich environment that we live in [8]. In response, the FDA loosened restrictions on ‘digital therapeutics’ to deliver mental health interventions during lockdown [9]. These interventions are available on accessible platforms such as phones and have been praised for making mental health care more affordable [10-11]. This decision was also praised for allowing data collection and feedback while helping those in need with an enjoyable experience [9].

‘Enjoyable’ is a key word here. Back in my article on how games can help with disabilities, I discussed how video games are perfect for making boring muscle-strengthening exercises fun, increasing the likelihood of these exercises being repeated. Mental health therapies such as Cognitive Behavioural Therapy (CBT) can come with homework tasks for you to complete [12]. As you can imagine, something called ‘homework’ may not be completed with glee [13], with particularly low completion rates in conditions such as Attention Deficit Hyperactivity Disorder (ADHD) [14]. But by gamifying homework and fleshing it out with narratives that keep users engaged, this can increase the likelihood of the tasks being completed [15-18].

In fact, Siriaraya et al. [15] describe how games can be used as a meta-therapy to increase treatment compliance. This was initially demonstrated in a game where cancer patients could destroy cancer cells as a method of showing chemotherapy’s effectiveness [19]. However, this could be redesigned to show how attending therapy, completing homework tasks, and reshaping flawed cognitions can help you to reach your treatment goals and become an improved version of yourself. Therapeutic video games can even adapt to the progress someone is making in their therapy, such as progress in the game Akali being dictated by the player’s ability levels [9].

So video games are affordable, can help with treatment delays, and can increase treatment effectiveness. Now, let’s take a look at what they can achieve in therapy.

Video Games and Depression

A review of video games and depression identified four key ways in which they can help users and their symptoms [20]. This is achieved by:

Reducing the stigma associated with depression and helping players to recognise depression symptoms in others;
Delivering emotional regulation and relaxation techniques to avoid worsening depression symptoms;
Identifying depression symptoms within themselves;
Delivering treatment such as CBT

The review found that video games were rarely used to identify symptoms of depression, but progress is being made on this. This year, the video game Thymia began to gain attention as a way to recognise depressive cues in an overburdened mental health system [21]. The artificial intelligence (AI) of Thymia uses a range of biofeedback such as facial expressions, reaction times and memory recall to help identify whether a person is experiencing depressive symptoms. While this seems overly simplistic on the surface, the aim is to use this alongside measures such as questionnaires to give therapists a more balanced look at someone living with depression. The creators of Thymia also aim for this to be used throughout mental health therapy as a way to gauge therapy’s effectiveness over time. At the time of writing, Thymia is undergoing clinical trials to test its effectiveness and further train its AI model. Watch this space!

In terms of treating depression, gamifying mental health treatment can directly target two key symptoms of depression: low mood and a loss of pleasure, otherwise known as anhedonia [3]. Video games are able to bring joy to those with depression [22-23], and not only can they increase motivation to engage with therapy [24-26], but they can activate a region of the brain known as the ventral striatum which increases reward sensitivity [27]. This is important as a symptom of depression includes lack of motivation by rewards [28], yet it seems video games can help with this.

By far the most common method of gamified treatment for depression is the gamification of CBT [29-45]. An example of a game designed to help with depression is a game known as SPARX [15]. SPARX teaches players healthier behaviours and coping strategies to help manage their depression via a level progression system [7]. Playing SPARX can not only lead to a significant reduction in depressive symptoms for players, but it can reduce the likelihood of depressive symptoms resurfacing (known as ‘remission’) by around 20% [45]. When talking directly to the players, they report feeling happy and satisfied with SPARX and view it as a useful alternative treatment method [46].

Gamified depression treatments don’t just have to adhere to traditional treatment methods such as CBT. A great example of this is a game called RehaCom, a neurocognitive remediation therapy game developed to target more neurological symptoms of depression such as attention and memory difficulties [47]. This game can be played at home rather than in a clinical setting, and following a five-week course of four weekly hour-long sessions, players reported improvements in their attention and planning skills and both their working and long-term memory.

RehaCom helps improve memory and attention symptoms of depression

When trying to capture the overall picture for video games and depression, it’s helpful to look for what is called a meta-analysis. In this context, a meta-analysis is when academics collect as many research findings as possible and reanalyse the data to gain an overall picture of the findings. I was luckily able to find a few meta-analyses in the realm of video games and treatment for depression. In a meta-analysis focusing on randomised controlled trials (RCTs; translation: a very high-quality and controlled method of research), the research team found that gamified mental health apps led to significant reductions in depressive symptoms with a moderate effect size [48]. A second meta-analysis on RCTs once again found that gamified mental health treatments had a small-to-moderate effect in reducing depressive symptoms [49]. While the overall findings are promising, the authors of the meta-analyses rightfully point out that effectiveness varied quite a bit for individual studies. This indicates a bit too much variation in how these studies are conducted, or perhaps that there are aspects of gamified mental health treatment that aren’t being sufficiently tapped into to create a universally effective experience.

If I could summarise the research base on gamified treatment for depression, it would be range: I was able to find a wide range of gamified treatments for depression that were used in a wide range of populations, ranging from children with cancer to indigenous families to veterans and the elderly [7]. Gamified treatment options were delivered in a range of platforms and game types, such as the previously-described SPARX on the app store, Boson X on PC to significantly lower ruminations in those with depression [44], and commercially available games such as Dance Central and Wii Sports to help reduce depressive symptoms [50-51]. Games can also take advantage of biofeedback such as heart rate monitors to teach relaxation and coping mechanisms for negative thoughts [44].

Along with its range, gamified depression treatments show a hopeful amount of versatility. A mobile game called Project: EVO was developed as an immersive game with goals and problem-solving. Despite this game originally being developed with children in mind [52], playing the game for 1-2 months can improve working memory and depressive symptoms in older adults [51; 53].

To wrap this section up, evidence suggests that video games can successfully target a range of depressive symptoms in a range of populations by using a range of gaming platforms.

Video Games and Anxiety

One of the first articles I wrote on my website looked at how video games can treat anxiety. I demonstrated that video games can be great at reducing anxiety by providing welcome distractions to both the mind and body. In this portion of the article, I will be focusing on anxiety disorders such as panic/anxiety disorder, Post Traumatic Stress Disorder (PTSD), and phobias.

To begin with, a good example of a game developed to help with anxiety disorders is MindLight. This is a neurofeedback game designed primarily for children to teach them how to cope with anxiety-provoking situations [52]. Children treated with MindLight still reported a reduction in anxiety symptoms three months after their treatment ended and players reported an enjoyable flow state while playing, along with improvements in their social literacy, social satisfaction, and social anxiety [54-55].

In The Netherlands, the narrative game ‘Één klein probleempje’ was developed to address cognitive biases associated with anxiety [56]. What this means is that people with anxiety disorders tend to perceive things as more threatening and anxiety-provoking than usual – think of someone who immediately thinks their boss is going to fire them when they receive an email. This game could be described as a ‘choose your own adventure’ game as players navigate branching pathways along the narrative. However, the game is cleverly designed to encourage players to pick the more positive situation – think of choosing to interpret your boss’s incoming email as praise for a job well done!

A great benefit of video games in therapy is the ability for it to supplement additional therapies. For example, it is not uncommon for someone experiencing anxiety to receive both talking therapies such as CBT and a medication such as a selective serotonin reuptake inhibitor (SSRI). Unfortunately, these medicines are not effective for everyone as they can have unpleasant side effects such as nausea and headaches [57]. A study by Fish et al. [58] compared the effectiveness of playing Plants vs. Zombies four times a week for 30-45 minutes to those taking SSRIs. They found that self-reported anxiety levels decreased more in the Plants vs. Zombies group than the medication group.

Reviews on gamified anxiety treatment generally find positive results. In Pallavicini et al.’s review [10], 12 studies showed that commercial video games (such as Plants vs. Zombies) successfully decreased anxiety symptoms. Of these studies, 9 of them showed improvements in anxiety symptoms higher than anxiolytic medication and alternative distraction techniques such as watching a movie or browsing the internet [58-61]. Similarly, evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback and virtual reality games on anxiety levels when compared with commercial video games (p=.03). [62], but this finding should be interpreted with caution due to the research team grading the quality of the research as ‘low’.

Interesting comparisons have been made between games specifically designed to treat anxiety symptoms and commercially available video games. An RCT comparing a biofeedback game called Dojo with Rayman 2: The Great Escape found that they were both equally capable of reducing anxiety levels in adolescents over three weeks [63]. Returning to the previously described MindLight, this too had comparable anxiety reduction abilities to a game called Max and the Magic Marker [3]. Commercial video games can also be helpful in reducing symptoms of PTSD in soldiers [59]. This is promising as widely available video games can be as helpful for minimising anxiety symptoms as specially-designed games.

While commercial video games can be as effective as tailor-made video games, it’s interesting to consider that video games can tap into aspects of therapy that may be difficult to achieve outside of a virtual world. For example, let’s say someone experiences arachnophobia, a fear of spiders. Due to the gradual nature of exposure therapy, this treatment may start with something simple like looking at pictures of spiders, but these pictures may not be accurate representations of what we fear. But in the virtual world, these can be much more accurate.

Enter virtual reality exposure therapy. Using a virtual reality headset, people can enter carefully crafted digital worlds that help them gradually overcome what they are fearful of while remaining in a safe environment. Virtual reality exposure therapy has not only been effective in helping with phobias such as arachnophobia [64-68], but can be useful in a range of situations such as overcoming social anxiety, public anxiety, exam anxiety, and driving anxiety [68-69].

Before we move on, it’s important to acknowledge that reviews of gamification and anxiety are not always positive. Abd-alrazaq et al.’s [62] review of gamified CBT found that 50% of studies did not find significantly lower anxiety levels [70-72], and referred to the quality of the research as ‘very low’. It is interesting to note that all of the studies in this review with no significant relationship were adolescents, while all significant relationships were found in adults, indicating that age may have an influential role in the effectiveness of the treatment.

Video Games and Autism

For those who are unfamiliar with autism, a person on the autistic spectrum can experience difficulties in social-emotional reciprocity, in nonverbal communication, and in developing, maintaining, and understanding relationships [20; 73]. A survey conducted by the National Autistic Society found that while 77% of adults diagnosed with autism would like to work, only 16% work full-time; difficulties with communication and social skills are a major barrier to this [74].

When improving social skills and relationships in children with autism, academics have stressed how therapists already have a powerful tool at their disposal – Minecraft [73]. Minecraft is noted to be popular with children with autism due to its highly creative nature and its ability to relax overstimulated and stressed children [75].

Cadieux et al. [73] make two particularly great points in their paper on the benefits of Minecraft. Firstly, they note that safe and secure Minecraft servers such as Autcraft already exist and can be promoted to children with autism to practice their social skills and make new friends. Secondly, they encourage therapists to actually get in there and experience Minecraft with their client. This would allow for supervision in a natural habitat where the young person feels comfortable, and could allow the therapist to make observations and take notes on what the child may need to work on in the future. There’s also the extra benefit of the child’s therapy session being a fun game of Minecraft! I’ll round this section off with a very nice quote from the authors of this paper:

…the very use of Minecraft as a tool for supporting the reinforcement of a positive social communication skillset is in a way, an approach which is aligned to, rather than opposed to, particular aspects of neurodiversity.

– Cadieux et al. (2020)

Video Games and Attention Deficit Hyperactivity Disorder (ADHD)

If you keep up to date with video game psychology news, you may be familiar with news on video games and ADHD. During the pandemic, a game called EndeavorRx made headlines as a prescribable video game used to help treat ADHD. I wrote my own article on EndeavorRx, but I would also like to bring two more games to peoples’ attention.

Before we begin, let’s take a look at why researchers have taken to prescribing video games for ADHD. ADHD impacts an estimated 4-8% of children globally [76], and its symptoms include, as the name implies, attention deficits, hyperactivity, and impulse control difficulties, but may also include symptoms such as poor social skills and struggling with time management [77-79]. These symptoms can unfortunately manifest in poor academic performance and strained relationships [80-81]. While medication can help with the attention aspects of ADHD, it may not be as helpful for social or daily functioning skills [82]. While therapies have been designed to target these aspects, participants frequently drop out of these treatments due to lack of attention and motivation [83-85]. It is this lack of attention and motivation that has encouraged therapists to consider new strategies – why not gamify these treatments to make them more engaging and fun [14]?

The first game that we’ll be looking at is a virtual reality game known as The Secret Trail of Moon (TSTM) [86]. TSTM is a game composed of multiple minigames designed to target aspects of ADHD such as maintaining attention and controlling impulses, improving working memory (think of remembering a phone number by the time you reach somewhere to write it down), improving visuospatial abilities, and improving planning skills. While I believe this game is still in the testing phases, it appears promising. TSTM was considered enjoyable as 86% of participants said they had fun playing it, and nearly every minigame had an ‘easy to play’ score of over 80%. However, 14% experienced motion sickness, suggesting that some minigames may still need tweaked to improve playability and reduce motion sickness.

Our second game, Plan-It Commander, focuses on improving aspects of daily life such as time management, planning and organising, and cooperating with other children [87]. This game was assessed in 88 children diagnosed with ADHD aged between 8-12 years over a 20-week period. Researchers also gathered data from parents and teachers to gauge whether playing the game was paying off according to other sources. Children with ADHD who played Plan-It Commander had significantly better parent-rated time management skills, working memory and responsibility skills with small-to-medium effect sizes, but we did not see significant changes in planning/organising or in cooperating with other children. While these findings are indeed promising, they indicate that gamified treatment options for ADHD may target certain components of ADHD better than others.

Video Games and Other Mental Health Conditions

Throughout my research, I was able to find evidence for how video games can be helpful for mental health conditions other than those previously listed. These include: addiction, bipolar disorder and schizophrenia.

Video games may be able to target specific aspects of addictions to improve treatment performance and adherence. As addiction is associated with personality traits such as impulsivity and thrill seeking [88], mundane treatments and homework tasks that feel like a chore to complete may be ignored or dropped out of. van Dooren et al. [89] has taken advantage of this in their game ReadySetGoals. When presented with a list of CBT tasks to complete, players can place bets on themselves completing this task, and will receive an in-game currency payout when they complete it. This is a fun way to incentivise players to complete tasks and invest in themselves while also receiving a fun reward for completing a task.

Individuals diagnosed with bipolar disorder can experience alternating episodes of depression and mania (hyperactivity) [90]. A game called BIPOLIFE was developed to help adults with bipolar disorder and was tested on a sample of 20 adults with a mean age of 47 over 12 weeks [91]. In this game, players control an avatar with bipolar disorder as they navigate through everyday life with the aim of teaching mood regulation and encouraging them to take their medication (known as medication adherence). Compared to the group who did not play BIPOLIFE, players had significantly higher medication adherence and had more positive attitudes towards their medication one month after playing, but not four months after. These findings suggest that video games can be a great way to encourage the taking of medication, but their effects may wear off over time.

Schizophrenia, which people may confuse for bipolar disorder and vice versa, involves hallucinations, delusions, confusion and avoiding others [92]. Video games have been used to improve emotion recognition abilities in those with diagnosed schizophrenia. Firstly, the video game VOICES was played in a study of 27 adults with a mean age of 41 years [93]. In VOICES, players listen to an audio clip and have to correctly guess which emotion is being conveyed, with each session increasing in difficulty regarding tone ambiguity. After playing for 30 minutes twice per week for one month, players saw significant improvements in their ability to recognise the correct tone in a person’s voice. Secondly, a game known as I am Learning Facial Expressions (ILFE) was also successful in helping players to correctly identify facial expressions [94]. While exploring the evidence on schizophrenia, it’s important to acknowledge that one game, Pear-004, was not effective in managing key symptoms of schizophrenia [95].

Critique

No field of research is without its problems, and as usual, I would like to take readers through some general critiques and discussion points on the quality of the research for video games and mental health therapy.

I would once again like to reiterate that I am absolutely not advocating for people to self-medicate with video games. The research presented in this article often either talks about supplementing therapy with video games, or video games being delivered with the support of therapists, or even video games encouraging the taking of medication. Please seek help if you are experiencing mental health difficulties, please do not attempt to ‘self-medicate’ yourself with video games.

If you still aren’t convinced that self-medicating with games is a bad idea, consider that games may not even be effective for you. For example, while CBT-based games are helpful for anxiety, exercise-based games didn’t seem to be [62]. Six et al. [96] argue that gamification is great for conditions such as anxiety and chronic stress, but may be less effective for conditions such as depression that include anhedonia in its symptom cluster and may dampen reward sensitivity [3; 97-99]. We also have to be careful when prescribing video games to those with ADHD due to its association with addiction [86; 100]. So while there’s evidence for the effectiveness of video games, we have to be selective in the types of video games we apply to different symptoms and mental health conditions.

While this article presents evidence on video games and therapy, it is important to have high-quality evidence. I managed to find two papers that evaluated the quality of research on anxiety and serious games in mental health respectively [52; 62]. In the anxiety assessment, research was often graded as ‘low quality’ due to factors such as risk of bias, small sample sizes, and samples consistently being from one country. Findings were mixed in Dewhirst et al.’s review [52] as studies such as the previously-discussed BIPOLIFE ranked highly in quality, while ILFE ranked poorly. Dewhirst et al. make suggestions for how the quality of video game research can be improved, such as larger sample sizes, longer follow-up periods to see the long-term effects of video games, and more research exploring the right ‘dosage’ of video games as gaming rates varied a lot in these studies [10]. It’s important to note that we just need more research into video games and therapy in general. A meta-analysis by Lecomte et al. [101] found that at the time of the study, only 3% of apps designed to help with mental health have been sufficiently validated through research. Which leads nicely into our next point.

Six et al. [96] analysed data from 38 studies with over 8000 participants on the effectiveness of mental health apps for depression. They found small-to-moderate effectiveness for these apps, but interestingly, apps which were specifically designed to be gamified were not significantly more effective than standard mental health apps. The researchers suggest that rather than gamification, mental health apps can be effective due to having guidance right from your pocket and digital reminders.

Finally, it is common for the effectiveness of video games to be assessed with measurement tools such as before/after scores on a questionnaire. This leads us to question what is called the ecological validity of these studies. Ecological validity refers to how well findings and changes apply to real life. For example, it would be great to know how often VR games designed to combat debilitating public speaking anxiety culminated in the user successfully speaking in public. This could be helped with the combination of more research in general and research with longer follow-up periods to see the long-term and real-life effects of these studies.

This is a really interesting and promising field of research, and I can’t wait to see what the future holds regarding it!

Summary

Video games have been selected as an alternative/supplementary type of mental health treatment due to factors such as large backlogs in the mental health system, healthcare costs, and difficulties with face-to-face treatment. Games can also make therapy homework tasks more enjoyable and can encourage users to adhere to their current treatment plans (e.g. taking medication).
Video games can identify and target symptoms of depression such as low mood and anhedonia, and gamified cognitive behavioural therapies (CBT) for depression appear to be effective. Games can also be tailor-made to target specific symptoms of depression, such as RehaCom improving memory difficulties for those with depression. Depression treatments are effective for a range of different age groups on a range of different devices.
For anxiety, video games can be an effective companion therapy free from harmful side effects, and can utilise biofeedback technology to teach children coping mechanisms for their anxiety. Evidence indicates that commercial video games such as Plants vs Zombies and Rayman can be as effective as tailor-made video games for treating anxiety. Virtual reality technology can successfully be used to treat phobias of creatures, social situations, driving and more.
Academics have promoted Minecraft as a creative, fun and natural way to observe and promote social skills in those with autism. This can be facilitated by safe and friendly Minecraft servers such as Autcraft.
EndeavorRx has previously gained media attention as a prescription video game treatment for ADHD. However, other video games such as The Secret Trail of Moon and Plan-It Commander can successfully target aspects of ADHD such as time management, working memory and responsibility.
Video games can motivate those with addictions to complete CBT tasks by placing bets on themselves. Games can also increase the likelihood of those with bipolar disorder taking their medication, and can help those diagnosed with schizophrenia in recognising facial expressions and tone of voice.
Research on video games and mental health therapy can be critiqued for its use of small study samples, its risk of bias, ambiguity regarding the required ‘dose’ of a video game, gamification versus the convenience/presence of a phone app, and whether the findings of these studies translate to real-life success.

Credits

A big thank you to DECosmic for designing my header image and to LoopyGc for drawing the header art.

This hard work would not be possible without the support of my wonderful Patrons. I would particularly like to thank my Platinum Patrons: Albert S Calderon, Kyle T, redKheld, Hagbard Celine, Aprou, Austin Enright, NotGac, Shaemus, Joey Rodriguez, DarrenIndeed, Thomas Meszaros, Dr. Jhin, Mulgar, Tobias Svensson, RK_Rammy, and John Bauman. Thank you!

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References

Hello there, thanks for making it to the end! As mentioned in the introduction, I cited over 100 sources when writing this article. Since this is such a massive reading list that would artificially inflate the scroll bar, I have organised all of my sources in this Google Doc.