(This post includes material published in MindCafe.)
Videogames and mental health.
In psychiatry there are certain cultures that may pass us by, that nevertheless are of significant impact to our profession, and vice versa. One of these is the culture of those who identify as “gamers” – individuals with a shared enjoyment of videogames, that becomes more than a hobby and more linked to a shared social identity. It should be of no surprise, therefore, that DSM-V’s proposition of “Internet Gaming Disorder” was associated with more than some angst from this subgroup.
There was the standard accusations of pathologising normal behaviour, alongside DSM-V not going far enough to formalise the diagnosis, but there was and remains a considerable amoung of debate regarding this issue. The APA Taskforce commissioned in 2015 reviewed 170 studies, and the outcome was telling – finding inconclusive results between the studies, it was nevertheless published with a conclusion section suggesting a link between aggression and videogaming, shortly being followed by letters published by members of the very taskforce claiming improper internal conduct and biased reporting by other members.
On the other side, gamers themselves have taken the surprising task of advocating the use of games for mental health itself. Charities such as Child’s Play and Checkpoint support the provision of games for sick children, as well as directly for improving the mental health of gamers.
How can this be possible? There are interesting components within gaming itself that can potentially be harnessed for good.
Games (good games, anyway) are fun, and doing fun things reduces stress. This does not indicate that all stress is negative, naturally, however a common feature of all mental health issues is the presence of stress, by means of impairment in psychosocial functioning. Whether this represents a temporary diversion or a neurotic escape fantasy, is a bit more of an issue for debate. However, ironically both of these elements are part of the second key issue of gaming.
2.) Flow theory.
The game design extension of behaviourism, with components rooted in operant conditioning. I once had a colleague describe flow theory to me as “brainwashing”, which was a nuanced approach to the concept. However, it simply refers to the issue of reaching an optimal state of immersion with an activity matched to their skill level. How is this achieved? By having escalating levels of difficulty that encourage stabilisation towards a state of regular engagement. Gamers like progression, and completing an activity with associated reward encourages further action.
Why is this relevant to mental health? Because of the issue of progression. Completing an activity is usually associated with a reward, however failure to complete the activity often requires penalty. The problem with penalty is that it robs one’s sense of progression and greatly increases stress associated with the event. Notably, different games deal with this mechanic in different ways – “casual games” often incur no penalty for negative activity. Penalty is often based on nonprogression – which is frustrating, however much less penalty than if one were to lose their previous achievements.
Games now exhibit suprising levels of maturity, and have evolved into a storytelling medium in many cases. Games involve an interactive experience as their base. Within this, there are several other options – incorporating a story is commonest, and greatly adds to the experience, but is not essential. What is fascinating, is that many games attempt to introduce philosophical concepts to gamers, with potential longstanding benefits.
The game “Braid” introduces considerable existentialist meditations into what superficially is a straightforward platformer. The Bioshock series is an excellent example of exploration of a deviant philosophy – the only problem is their interpretation of objectivism is more accurately ethical egoism, but I digress. Either way, the purpose of bringing a philosophical background to the game experience is that it encourages gamer to rethink circumstances – characters, motivations, etc. By doing so, this firstly teaches a level of psychological mindedness (being more aware of the thoughts of others and building empathy), but it also encourages self-exploration (reassessing how one makes decisions in their own life). Is it better to be the Ubermensch or the everyman? The favourite hero or the quiet champion?
Philosophy also does not even require dialog, but merely a quiet opportunity to introduce shades of grey to a normally uncomplicated world. There is the intense moral ambiguity of Shadow of the Colossus, with a disdain for your own actions despite not a word being uttered. The Legend of Zelda series has as an essential underlying theme of the key concept of growing up – in all of the games, the player faces obstacles, and then you learn from them so that you can deal with bigger obstacles later, very slowly growing stronger without even realising it. There is a reason why it has had such lasting intergenerational appeal.
Some games have attempted direct psychoeducation. There are several games that deal with the plight of the individual’s descent into a deteriorating world – such as Game Lab’s Elude, or Depression Quest. These seek to evoke the experience of a mental health issue, in order to raise awareness and encourage people to seek help. They either use highly evocative imagery to create the experience of what it would be like to have a mental health issue, or have explicit textual references to the experience and information about things such as sleep, abnormal cognitions and so on.
However, it’s a fine line to tread between raising awareness and piecemeal interventions within broader exploitation. We would not consider reading a book on depression to be sufficient treatment for same, although amongst us there are certainly advocates for bibliotherapy. When I’ve tried these games, as a mental health professional they appear either trite or alarmingly celebratory of negative thought patterns. There is probably more to be done, however, to refine the medium to meet better aims.
4.) Look left, look right.
One notices a pattern regarding all of the above components – they are largely opinionated and pontificating on potential interventions, rather than any hard evidence. There is in fact excellent evidence for the direct benefits of videogames on mental health, however they are in a fairly lateral fashion.
In 1987, Dr Francine Shapiro popularised a new form of psychotherapy known as EMDR, which stands for eye movement desensitization and reprocessing. A possibly apocryphal anecdote is that she was watching train tracks during a long ride, and noticed that the act of looking at alternate tracks was deeply calming. Although the psychotherapy itself includes eight formal steps, it is the fourth step – desensitisation – that is related to the above, and also its most controversial, as it’s achieved by bilateral stimulation.
“Originally, bilateral stimulation has been obtained through pursuit eye movements in response to the therapist fingers’ movement or using ad hoc technical devices to simulate this movement (Shapiro, 2001). Such movements are usually elicited in the horizontal plane (left-right), but they can also use vertical, oblique or ellipsoid trajectories. Importantly, bilateral stimulation cannot only be visuomotor but also auditory (i.e., a sound alternating in left and right ears) or tactile (i.e., a stimulation of any left-right part of the body; Shapiro, 1994, 2001). Therefore bilateral stimulation per se, i.e., regardless of sensorimotor modality, seems to be more relevant to EMDR effects than eye movements on their own.” Coubard, 2016, Frontiers in Behavioral Neuroscience 10:52.
This is highly divisive within the scientific community, with about half remaining skeptical of the bizarre notion that looking left and right can help your mental health. However, there are a number of neuroscience-based theories that may explain its effects – hemispheric synchronisation, left-right eye movements that naturally happen during REM (rapid eye movement) in sleep, distraction – but the objective effects remain reasonable.
Which now brings us to videogames – specifically, Tetris, which was shown in 2009 to reduce susceptibility to PTSD by Holmes and colleagues. 52 people were asked to watch traumatic clips from public safety videos, and then revisited the concepts via still images from the videos, then divided into groups to play the game for 12 minutes, or sit doing nothing for 12 minutes. Over the next week, the gameplayers experienced 51% fewer intrusive memories than the group that didn’t.
The study has attracted considerable attention in showing a verifiable change to susceptibility to what is a very debilitating mental illness, and many theories have been put forward regarding its effect. However, one must consider what the player’s eyes are doing in Tetris – specifically, the design of the game, with the left half of the screen showing the falling blocks, and the right side showing what the next block is that you are due to receive. There are numerous other games which retain similar mechanics – “Breakout”, most “running games”, sporting simulations, and so on.
Videogames are fun, and a rewarding hobby for many. Like anything else, they can be overindulged. What’s fascinating about them is how much technology has changed to allow them to become something very different – a storytelling experience, an opportunity for rumination, a sandbox for terrible ideas or a breeding ground for good ones. As with any indulgence, there can be considerable negative effects from them. However, we may just be scratching the surface of their benefits.