The Gamification of Acceptance and Commitment Therapy May Improve Well-Being

Source: Proxima Studio on Adobe Stock / With Permission

Video games are a popular form of entertainment enjoyed by both younger and older individuals across the globe. There are approximately 2.95 billion active video gamers across the world. Furthermore, about 50 percent of Europeans play video games between the ages of 6 and 64. These statistics are similar in the US, with 64 percent of adults and 70 percent of individuals under the age of 18 who play games regularly.

There are many genres and sub-genres of video games such as puzzles, adventures, action, simulations, sandboxes, sports, multiplayer online, real-time strategy, first-person shooters, and others. Each of these uses different sets of cognitive skills (motor ability, memory, problem-solving skills) and has shown in some cases to improve decision-making and other cognitive skills [1].

More recently, many apps have focused on developing and improving mood and mental health such as headspace and mindfulness skills, but there has been little attempt to develop complex adventure games that support mental health and build psychological flexibility and resilience.

There is a silent worldwide mental health epidemic but few people talk about it due to stigma. As a result, and little effort to tackle the problem at a societal level, mental health is not just avoided in conversation, but it is also normalized in society. The prevalence of mental health problems is shocking, with approximately 251 to 310 million people suffering from depression, and 275 million from an anxiety disorder, globally. The cost of mental health problems to the global economy by 2030 is predicted to amount to $16 trillion. Depression is estimated to outpace ischemic heart disease as the number one cause of disease burden globally by 2030 [2].

In addition to the vast prevalence of poor mental health, the problem is further compounded as many health care systems globally are not prepared to cope with the problem. According to the World Health Organization: "Health systems have not yet adequately responded to the burden of mental disorders. As a consequence, the gap between the need for treatment and its provision is wide all over the world."

Traditional forms of psychotherapy have focused on a personal therapist and client in-person sessions, or talking therapies. These can be in the form of second-wave behavioral therapies such as cognitive behavioral therapy (CBT) or third-wave therapies such as acceptance and commitment therapy (ACT) or many other types. However, these therapies are often too expensive for many even in wealthy countries such as the US. There are even worse accessibility problems in low- and middle-income countries (LMICs), referred to as the treatment gap, whereby LIMICs have less access to treatment than in wealthier countries [3].

The World Health Organization has proposed plans to engage in digital health strategies, called the global strategy on digital health, to help deal with health (including mental health) and the treatment gap. They urged member states to "consider drawing up a long-term strategic plan for developing and implementing eHealth services to develop the infrastructure for information and communication technologies for health to promote equitable, affordable, and universal access to their benefits."

In addition to the treatment gap problem, digital health applications may be useful for younger generations who find these digital platforms more inviting and accessible. Indeed, there have been a few applications of video games to support mental health. One of these is called PlayMancer, which attempts to build emotional regulation skills and reduce impulsivity [4]. Another game called Dojo also attempts to develop emotional regulation by reducing anxiety in adolescents [5]. Though these games may be useful as they focus on direct emotional outcomes, they ignore underlying psychological processes.

In my lab, we have developed ACTing Minds that focuses on building underlying psychological processes. This game, based on acceptance and commitment therapy (ACT) focuses on building overall psychological flexibility through three key components of ACT:

1. Acceptance – openness to pain
2. Values identification – identifying what is meaningful to you in the here and now
3. Cognitive diffusion – recognizing thoughts are just thoughts and that you should not buy into them.

In the game, you must engage in ACT-based exercises to

1. move the character in the direction of accepting the loss of his wife after a recent tragic accident
2. move the character away from avoidant behavior such as thought suppression
3. help the character become aware that thoughts are just thoughts and not to buy into them
4. identify and orientate the character toward important values in his life

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Crucially, teaching young people mental health skills, and building resilience and psychological flexibility early are important. Rather than firefight the problem of mental health as it progresses into adulthood, we should be identifying novel approaches to help young people to build mental health skills early so that they are better prepared to cope with many of the struggles they will face in the future.