Video gaming has become a recreational staple for a global audience (Shafer & Carbonara, 2015), transforming the experience of leisure into an engaging virtual activity which was only exacerbated during the COVID-19 pandemic (López-Cabarcos et al., 2020). The psychological impact of video gaming has been explored through a variety of lenses, with addiction (André et al., 2020; Aarseth et al., 2017), aggression (Burkhardt & Lenhard, 2022), social interaction (Arbeau et al., 2020; Kowert & Oldmeadow, 2015), and exergames (video games that require the player to physically interact with the game to play it; Halbrook et al., 2019) becoming some of the most academically examined categories. However, a growing body of work has focused on the use of the ‘serious game’ (Deterding et al., 2011), which generally provides more educational or behaviour change-focused experiences rather than purely entertainment-based experiences associated with commercial off-the-shelf games (COTS; Connolly et al., 2012).
However, previous research has taken issue with differentiating between COTS games and serious games through their use of entertaining gameplay. Laamarti et al., (2014) suggest that due to the lack of conceptualisation or availability of game design intention on the game developer’s part, it would be more sensible to define a serious game in terms of its potential. Serious games have the potential to include elements of entertainment (Jantke, 2010) as well as incorporate multimodal interactions that aim to provide a more engaging experience (Arnab et al., 2011).
Based on this definition, some recent examples of serious games include Pokémon GO (Nintendo Co.; Althoff et al., 2016), which encourages players to explore the outside world in an immersive activity to catch Pokémon, which promotes increased physical activity (Khamzina et al., 2020); Orwell: Keeping an Eye on You (Osmotic Studios; Caserman et al., 2020), a game that encourages critical thinking about topics like state surveillance and freedom of speech; Hellblade: Senua’s Sacrifice (Ninja Theory; Fordham & Ball, 2019), a game that fosters an understanding of the psychosis experience and addresses stigma as players step into the shoes of a Celtic warrior and experience her psychological struggles (Ferchaud et al., 2020), and an adaptation of the popular title Tetris which focuses on sustainability, known as Eco Tetris (de Sá Escudeiro et al., 2022).
The key to an effective serious game appears to lie in its ability to stabilise and maintain positive mood states (Nazry & Romano, 2017) while providing the player with opportunities to navigate academic contexts in a game environment (Lameras et al., 2017). The affordances of video games, such as positive feedback loops and realistic storytelling, allow the player to effectively consume the core message of the serious game whilst engaging in an enjoyable activity (Zhonggen, 2019). This has been supported by previous research (Connolly et al., 2012) that suggests that the gamified ‘style’ of interacting with educational content appears to engage players more effectively rather than any inherent benefits of the game itself.
Initially used for education and learning purposes, traditional serious games have also become a particularly appealing tool in mental healthcare (Dewhirst et al., 2022; Lau et al., 2017). The integration of serious games in mental health treatment aligns perfectly with the digitalisation of healthcare delivery and the increasing demand for accessible, evidence-based interventions (Lattie et al., 2022). However, the question remains as to how serious games can fill the need for accessible interventions within the field of mental health treatment.
Firstly, like COTS video games, the interactive and motivating elements of the serious game can instil a sense of empowerment and control over one’s thoughts, feelings, and behaviours and encourage the user to take active steps towards their mental health recovery (Jankowksi et al., 2022; van der Lubbe et al., 2021). Secondly, many may be reluctant to engage with the more traditional forms of talking therapies, or these may not always be readily available. Therefore, serious games could represent a more desirable and/or within-reach alternative (Miranda et al., 2022; Ruiz et al., 2022). Thirdly, serious games can be easily adapted to include appropriate evidence-based therapeutic approaches, such as neurocognitive rehabilitation, cognitive-behavioural therapy, or exposure therapy, and address the needs of different groups, making them suitable for a wide range of mental health conditions (Gamito et al., 2010; Lopes et al., 2021). In addition, if well-integrated within the mental healthcare system, serious games could provide valuable insights into users’ behaviours and treatment progress, allowing mental health practitioners to deliver more personalised, effective care and potentially save costs (Dewhirst, Laugharne & Shankar, 2022; Fovet et al., 2017).
Despite this appeal, it is unclear whether serious games have the clinical efficacy necessary to be utilised as treatments for mental health issues. In previous meta-analyses of randomised controlled trials (RCTs), Abd-Alrazaq and colleagues (2022a; 2022b) found that serious games were more effective than no intervention and as effective as traditional interventions in reducing symptoms of depression and anxiety, respectively, whilst Lau et al., (2017) suggests that serious game use was preferrable to no intervention at all. The authors conclude that serious games had a moderate effect on improving health outcomes, including depression (n = 2), post-traumatic stress disorder (n = 2), autism spectrum disorder (n = 2), attention deficit hyperactivity disorder (n = 1), cognitive functioning (n = 2), and alcohol use disorder (n = 1).
However, a consistent criticism of current research was the questionable quality of methods used in this field, with eleven of the fourteen studies used in the review scoring a ‘moderate’ level of study quality or lower. As you can see, this leaves a complicated trail of questionable evidence for researchers to follow. Although the authors remark that serious games could be a useful vehicle for mental health interventions, several obstacles lie in the way of effectively implementing serious games in a clinical environment. Primarily, study quality needs to improve, and a focus on more RCTs is generally recommended for future research in this area, with a further recommendation for partnerships between stakeholders in research, healthcare, and the gaming industry to improve both quality and quantity of opportunities for serious game design and implementation.
Consequently, the evidence presented so far may not fully reflect the targeted therapeutic effectiveness of serious games for mental health conditions. Direct comparisons with both active and control interventions were extremely limited in some research, making it challenging to draw definitive conclusions about the effectiveness of serious games as standalone interventions (Abd-Alrazaq et al., 2022a; 2022b). Moreover, it is not clear whether the studies evaluated so far had any potential adverse effects associated with the use of serious games (e.g., distress, non-compliance, addiction, etc.) or whether they measured outcomes beyond symptom reduction (e.g., functional improvements, quality of life, treatment satisfaction, etc.), both of which are fundamental in a clinical context.
While serious games hold great potential to complement existing therapeutic approaches, their effectiveness needs to be rigorously evaluated through high-quality research before putting forward any firm recommendations to mental health practitioners and policymakers. Furthermore, as serious games gain popularity within mental healthcare, ethical considerations and user safety remain crucial aspects to consider. Ongoing collaboration between game developers, mental health experts, including mental health service users, and researchers can address these concerns and encourage accessible, novel, mental health treatments with the help of serious games.
Author Bio: George is a Doctoral Researcher at the University of Westminster, studying motivations for video game play and the effects of gameplay on mental health factors, such as stress and psychological well-being. George enjoys playing action-adventure games and Dungeons & Dragons in his spare time. Twitter: https://twitter.com/cybergamepsych Personal Blog: https://psyquestblog1.wordpress.com/
Raul is an applied psychologist with interests in digital technologies, healthcare education, and mental health. As part of his PhD research at the University of Surrey, he is investigating the use of immersive virtual reality as a tool for building empathy and reducing stigmatising attitudes towards patients with mental health conditions among those preparing to become health professionals. Twitter: https://twitter.com/raulszekely1
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