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PhD Research Proposal

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Provisional Title: ​Developing Video Games for Mental Health
Topic: ​Video Games, Empathy Games, Serious Games, Gamificati...
(Square Enix, 2015), ​Night in the Woods ​(Infinite Fall, 2017), ​Celeste ​(Matt Makes Games Inc., 2018) and
The Town of L...
good. ​iThrive Games, ​an organization supported by The D.N. Batten Foundation and Centerstone
Research Institute, also re...
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PhD Research Proposal

  1. 1. Provisional Title: ​Developing Video Games for Mental Health Topic: ​Video Games, Empathy Games, Serious Games, Gamification, Psychology, Mental Health, Mental Illness, Mental Health Awareness, Therapy and Game-Based Intervention According to the World Health Organization, more than 450 million people worldwide suffer from mental illness, but unfortunately more than half remains undiagnosed and untreated, because of the stigma and discrimination (World Health Organization, 2001). Video games are an increasingly popular medium with 2.2 billion active gamers in the world, and are expected to generate $108.9 billion in game revenues in 2017 (Newzoo, 2017). Video games are a medium in the same way as books and movies, and can have different genres and can tackle different topics, including mental illnesses such as depression. Due to their mass audience, the proposed research would like to study how video games can be utilized for mental health. Research Questions: The main research question is: “How to develop games for mental health?” There are two general types of video games for mental health: empathy games that aim to raise awareness for mental health and destigmatize mental illness, and therapeutic games, in the form of serious games or gamification, that aim to help people suffering from mental illness. The proposed research would like to look into both of these types of video games. Empathy games is category for video games that hopes to inspire players to walk a mile in someone else’s shoes (Solberg, 2016). According to Vander Caballero, the developer of Papo and Yo (Minority Media, 2012), in empathy games, the main experience is driven by players’ desire to understand and relate to the emotions of other avatars or players (Caballero, 2014). Some examples of empathy games are ​That Dragon, Cancer (Numinous Games, 2016), and ​Actual Sunlight (WZO Games, 2013), Depression Quest (The Quinnspiracy, 2013) and ​Elude (GAMBIT Singapore, 2010) that tackle the topic of depression. Serious games is a type of video games that are developed for purposes other than entertainment, such as for education, skills development or training for high-risk situations in a safe environment, including transforming mental health services (Reynolds et.al., 2017). Some examples of serious games are ​Sparx (University of Auckland, 2013) to treat depression, ​Champions of the Shengha ​(BfB Labs, 2017) and ReachOut Orb (ReachOut Australia, 2016) to increases mental fitness and wellbeing, ​Secret Agent Society​, formerly known as ​Junior Detective Training Program (Social Skills Training Institute, 2008) and Let’s Face It (University of Victoria, 2013) to treat autism spectrum disorder, and ​Braingame Brian (Gaming and Training Foundation, 2013) to treat Attention Deficit Hyperactivity Disorder. While gamification is a process that leverage game design elements to motivate people in a non-game context (Deterding, 2011). Some examples of gamification are ​Habitica (HabitRPG Inc., 2015) and SuperBetter (SuperBetter, 2012) that applies game elements such as achievements, levels and rewards to incentivize its users to live a better life and build resilience. Aside from these types of games, there are also video games that contains themes of mental health, even though it is not the main focus of the game, such as ​Hellblade ​(Ninja Theory, 2017), ​Life is Strange
  2. 2. (Square Enix, 2015), ​Night in the Woods ​(Infinite Fall, 2017), ​Celeste ​(Matt Makes Games Inc., 2018) and The Town of Light ​(LKA, 2016). Although not developed for mental health intervention, the game ​Journey (Thatgamecompany, 2012) has been explored by the Games and Emotional Health Lab for its therapeutic potential and promising intervention for depression (Gotsis, 2017). The proposed research also have a number of sub research questions that support the main research question. The first sub research questions is: “​How to accurately represent mental illness in video games​?” That Dragon, Cancer ​(Numinous Games, 2016) is about the real life story of the developers, Ryan and Amy Green, raising their terminally ill son, Joel. Green says, “I’m not sure if everyone who has played That Dragon, Cancer claims to have grasped what we went through, but they are now able to relate to it in a very personal way (Green, cited in Wells 2016)”. While according to Will O’Neill, the developer of Actual Sunlight, the game is “almost 100 percent autobiographical (O’Neill, cited in Smith 2015)”. However, it would be difficult for the proposed research to design a game based solely on personal experience. For the author’s Masters by Practice, she developed a point-and-click puzzle empathy game called Depression Simulator​. She wanted to create a game that is autobiographical but at the same time also represents more point of views about depression, so she solicited contributions in the form of stories, images and even music from the collaboration website ​HitRecord​. The proposed research would take a similar approach, and look into the values provided by lived experiences. For data collection, the author is currently developing an online platform where people suffering from mental illness can freely share their stories in the form of writings, images, video and music. The author will also use the platform to work closely with the community and ask for feedback and feedforward. In addition, the proposed research would also like to work closely with experts in psychology and mental health. Similar to ​Hellblade ​(Ninja Theory, 2017), where the main character suffers from psychosis, and the developers worked closely with Professor Paul Fletcher, a neuroscientist and psychosis expert at the University of Cambridge in order to portray psychosis as accurately as possible (Lloyd, 2017). The second sub research question is: ​“How to use video games to foster player empathy for mental health awareness?” There are two broad categories of empathy: emotional empathy and cognitive empathy. Emotional empathy is the automatic and often unconscious response to another’s emotions, while cognitive empathy is intentionally taking another person’s point of view (Hoffman, 1987; Stephen & Finlay, 1999). Some studies induce empathy in participants through experimental manipulation and compare their responses with control groups. These studies are more generalizable to the design of video games (Belman & Flanagan, 2010). Belman and Flanagan published a paper in the ​International Journal of Cognitive Technology as a resource for those interested in using video games to foster player empathy. They have also been working on a project called ​Values of Play that is devoted to assisting students in creating games for
  3. 3. good. ​iThrive Games, ​an organization supported by The D.N. Batten Foundation and Centerstone Research Institute, also released resources on design principles for designing empathy games. The proposed research will test the proposed design principles by both ​Values of Play and ​iThrive Games in the design and development of video games. The third sub research question is: “​What are the psychological and emotional benefits of playing video games?​” The proposed research will look into the psychological benefits of playing video games, building upon existing research on the topic. CheckPoint is a charity that connects mental health resources with video games and technology, including producing a series of videos and a compilation of papers about the psychological and emotional benefits of playing video games. In a paper by Ryan, Rigby and Przybylski, they looked into how games can be used to improve mood and how the mechanics of video games can relate to the well-established model of wellbeing in psychology, Self-Determination Theory (Ryan et.al., 2006). They conducted studies, letting participants play different types and games and then observed their wellbeing after playing. There have also been studies on how games can be used for relaxation, such as by observing the brain waves and heart rate variability of players as they played ​Bejewelled 2 (PopCap Games, 2004) and seeing how it relates to mood and stress levels (Russoniello et.al., 2009), and studying how the levels of immersion in games, such as ​World of Warcraft (Blizzard, 2004), correlated to the player’s wellbeing (Snodgrass et. al., 2011). Following up the previous question, the fourth sub research question is: ​“How to design video games for people suffering from mental illness?” The proposed research will look into the characteristics of video games with psychological and emotional benefits that were and were not necessarily designed to improve wellbeing, and apply those concepts in the design of video games for people suffering from mental illness. Champions of the Shengha ​(BfB Labs, 2017) ​makes use of biofeedback technology, in the form of a heart rate sensor, to train players in emotional regulation (Tucker, 2017). Following its success, ​Bfb Labs is currently developing another game to treat children with general anxiety disorder. While ​SuperBetter (SuperBetter, 2012) is a game that is designed to help people live a better life, including beating depression and overcoming anxiety. ​SuperBetter was validated in two clinical trials conducted at University of Pennsylvania, and at Ohio State University Wexner Medical Center and Cincinnati Children’s Hospital funded by the National Institutes of Health. The proposed research would also look into the gamification of mental health treatments, such as Cognitive Behavioral Therapy, similar to ​Sparx (University of Auckland, 2013). Sparx was developed by the University of Auckland in collaboration with young people to teach players mood management skills in a fantasy world where they have to get rid of gloom and negativity via different quests. Sparx has been tested through randomized control trials and have been found to be at least as effective as treatment as usual, and produced higher remission rates (Merry et.al., 2012).
  4. 4. Methodology and Research Tasks: Wesley Turner et. al. published a Primer for Developing Games for Mental Health, which included a checklist for the different stages of development: Conceptualisation, Project Planning, Developer Consultation, Ownership Rights and Adaptation (Turner et. al., 2016). The proposed research will adapt some of the stages of development where applicable. While Theresa Fleming et. al. identified four key ways for maximizing the impact of video games in mental health, namely: user-centered approaches, engaging and effective interventions, intersectional and international collaborations, and rapid testing and development (Fleming et. al., 2017). Review of Related Literature The proposed research will review related literature, and analyze existing video games and projects that focus on empathy, mental health and psychology in video games, including review existing research by the Creative Interventions, Art & Rehabilitative Technology (CiART) of the Centre for Game Design Research, proceedings from ​Symposium on Games for Mental Health at KU Leuven, Symposium on Computing and Mental Health at Chi Play Workshops. Data Collection As identified by Theresa Fleming et. al., it is necessary to have a user-centered approach, because the motivations and preferences of different user groups on their mental health needs are different (Fleming et. al., 2017). In order to cater to this, the proposed research will collect information through surveys and interviews from people with lived experiences, as well as consult experts in psychology and mental health. As mentioned before, the author is currently developing an online platform for data collection. Due to the sensitive nature of the proposed research, attention would also be given to address issues of confidentiality, such as people’s medical history, and ownership of people’s stories about their lived experience. Game Development The author is proposing a PhD by project and dissertation. The project should be undertaken as part of the PhD and not as a stand-alone project, because in order to develop video games for mental health requires diverse skills from both experts in psychology and mental health, and video game development (Fleming et. al., 2017), as well as significant research. The proposed project will apply the Agile Methodology for a rapid and iterative game development process. The stages of the game development are: Concept, Design, Development, Testing and finally Release. This methodology is chosen because this will allow the proposed research to receive feedback and feedforward which can be applied in the refinement of the video game. Rapid testing and implementation is also one of the ways identified by Fleming et. al. to maximize the impact of video games in mental health, because user expectations of video games evolve rapidly (Fleming et. al., 2017).
  5. 5. During the Concept stage, the proposed research will answer a few questions identified by Turner et. al. at their Conceptualisation stage, such as the purpose of the game, underpinning theories for the game, the intended target audience (Turner et. al., 2016). During the Design stage, the proposed research will answer a few questions identified by Turner et. al. at their Project Planning and Developer Consultation stage, such as the game genre, potential barriers that may impede game development, the game’s expected assessment or treatment outcomes, ideas for gameplay, essential and non-essential aspects of the game, such as narrative and level design, and platform of delivery (Turner et. al., 2016). The psychological theories will also need to be identified at this stage (Turner et. al., 2016), as well as how it can be translated to game mechanics (Tujinman et. al., 2017). Currently, games for mental health have been predominantly delivered via PC (Kharrazi et. al., 2012; Rahmani et. al., 2012) with a small percentage delivered via mobile devices (Kharrazi et al., 2012). The proposed research will consider both these platforms, as well as new platforms such as virtual reality. Based on the game design, tools needed to develop the game, such as game engines and softwares, will be identified. The scope and scale of the game design will also determine if the proposed research will need to collaborate with other game developers, such as additional programmers, artists and sound designers, on the project. The game will be tested and released to a test group, and iterated based on feedback and feedforward. In order to properly evaluate the game’s expected assessment or treatment outcomes, new assessment and monitoring tools may need to be developed as the most intervention studies are assessed through self-report measures (Tujinman et. al., 2017). Randomized Control Trials may also be used to measure the treatment outcomes. Resources Needed: The proposed research would require a computer and softwares for development, test devices, server for hosting the developed video games, and developer accounts for publishing the developed video games. Potential Audience: Listed below are examples of conferences and journals that focused on game development, as well as the intersection between psychology and media: ● Transactions of the Digital Games Research Association ● Journal of Media Psychology ● Journal of Computer Games and Communication ● Well Played Journal (Carnegie Mellon University) ● Computer Games Journal ● Games for Health Journal The intersection between psychology and mental health with video games is a topic that is starting to gain more traction with the help of organizations such as the aforementioned ​iThrive Games​, ​BfB Labs and CheckPoint,​ and ​Gaming the Mind ​by​ ​Royal College of Psychiatrists.
  6. 6. There are also a number of conferences that were about games for mental health, such as the aforementioned Symposium on Games for Mental Health at KU Leuven, Symposium on Computing and Mental Health at Chi Play Workshops, and Games for Change, which empowers game developers to use games and technology to make the world a better place. Beyond academics, the game industry and its conferences have also included talks and panels about games for mental health, such as at Develop, PocketGamer Connects and GDC. In the independent games community, the Asylum Jam is held yearly to challenge developers to explore outside of negative mental health stereotypes in video games. The proposed research will also be of interest to the general public, as it aims to use video ​games for mental health awareness and for people suffering from mental illness. BIBLIOGRAPHY World Health Organization. (2001). Mental disorders affect one in four people. http://www.who.int/whr/2001/media_centre/press_release/en/ Newzoo. (2017). Global Games Market Report. https://newzoo.com/solutions/standard/market-forecasts/global-games-market-report/ Solberg, D. (2016). The problem with empathy games. https://killscreen.com/articles/the-problem-with-empathy-games Caballero, V. (2014). Empathetic Games Are Here to Stay! What's Next? https://www.gdcvault.com/play/1020598/Empathetic-Games-Are-Here-to Reynolds, L.M., Hodge, P. & Simpson, A. (2017). Serious Games for Mental Health. Journal of Psychiatric and Mental Health Nursing. Deterding, S., Dixon, D., Khaled, R. & Nackle, L. (2011). From game design elements to gamefulness: defining gamification. Proceedings of the 15th international academic MindTrek conference: Envisioning future media environments. Gotsis, M. (2017). Beyond Sadness and Smiles: How to Harness the Potential of Video Games for Treatment of Depression. Proceedings of Symposium on Computing and Mental Health at Chi Play 17 Workshop. Wang, B. (2016. Person to Person: Reading People Through Video Games. https://www.popmatters.com/person-to-person-2495438058.html Smith, E. (2016). ‘Actual Sunlight’ Might Be the Most Painfully Real Video Game You’ll Ever Play. https://www.vice.com/en_ca/article/4wbn9d/actual-sunlight-might-be-the-most-painfully-real-video -game-youll-ever-play-000
  7. 7. Wells, J. (2016). From Project Syria to That Dragon, Cancer: the rise of empathy video games https://www.telegraph.co.uk/men/the-filter/the-surprising-rise-of-empathy-video-games/ Lloyd, J. (2017). How Hellblade: Senua’s Sacrifice deals with psychosis. http://www.sciencefocus.com/article/mind/hellblade-senua%E2%80%99s-sacrifice-psychosis-inte rview Belman, J. & Flanagan, M. (2010). Designing games to foster empathy. International Journal of Cognitive Technology. Hoffman, M. (1987). The Contribution of Empathy to Justice and Moral Judgment. In N. Eisenberg & J. Strayer (Eds.) Empathy and Its Development (pp. 47–80). Cambridge: Cambridge University Press. Stephan, W. & Finlay, K. (1999). The role of empathy in improving intergroup relations. Journal of Social Issues, 55(4), 729-743. Tucker, J. (2017). Behind the tech of BfB Labs biofeedback card battler Champions of the Shengha. https://www.mcvuk.com/uncategorized2/behind-the-tech-of-bfb-labs-biofeedback-card-battler-cha mpions-of-the-sheng Hazel, J. (2018). ​The Psychological and Emotional Benefits of Video Games: Clinical Research. https://checkpoint.org.au/psychological-emotional-benefits-video-games-clinical-research/ Ryan, R., Rigby, C. & Przybylski, A. (2006). The motivational pull of video games: A self-determination theory approach. Motiv Emotion, 2006: vol. 30, pp. 347-363. Russoniello, C., O’brien, K. & Parks, J. (2009). EEG, HRV and Psychological Correlates while Playing Bejeweled II: A Randomized Controlled Study. Stud Health Technol Inform. 144:189-92. Snodgrass, J., Lacy, M., Francois, H., Fagan, J. & Most, D. (2011). Magical flight and monstrous stress: technologies of absorption and mental wellness in Azeroth. Cult Med Psychiatry. 35(1):26-62. Merry, S., Stasiak, K., Shepherd, M., Frampton, C., Fleming, T. & Lucassen, M. (2012). The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. https://doi.org/10.1136/bmj.e2598. Turner, W., Thomas, B. & Casey, L. (2016). Developing Games for Mental Health: A Primer. Professional Psychology: Research and Practice. 47. 10.1037/pro0000082. Fleming, T., Bavin, L., Stasiak, K., Hermansson-Webb, E., Merry, S., Cheek, C., Lucassen, M., Lau, H., Pollmuller, B. & Hetrick, S. (2017). Serious Games and Gamification for Mental Health: Current Status and Promising Directions. Front. Psychiatry 7:215. doi: 10.3389/fpsyt.2016.00215 Tujinman, A. & Weerdmeester, J. (2017). Current Opportunities in Research and Development of Games for Mental Health. Proceedings of Symposium on Computing and Mental Health at Chi Play 17 Workshop.
  8. 8. Kharrazi, H., Lu, A. S., Gharghabi, F., & Coleman, W. (2012). A scoping review of health game research: past, present, and future. Games Health J, 1(2). doi: 10.1089/g4h.2012.0011. Rahmani, E. & Boren, S.A. (2012). Video games and Health Improvement: A Literature Review of Randomized Controlled Trials. Games Health J, 1(5), 331-341. doi: 10.1089/g4h.2012.0031.

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