Levelling Up In Life: Lessons from Game Design for App-Based Anxiety Treatment

As I’ve discussed over the last couple of weeks, I’m currently without a job, which isn’t the greatest. Last week, however, I had an interview at a company which develops an app for people suffering from autism (and has now branched out into anxiety, PTSD and other conditions), and I’ve been invited back on Monday for a second interview. As part of this, I need to do a five-minute presentation on the topic of gamification and what lessons game design can teach designers of apps for people with anxiety. It’s a nice topic, one they’ve picked for me because they figured I might have something interesting to say about it, and I’m looking forward to it!

Although it’s a topic I’m definitely interested in, and one I think I certainly could hold a decent conversation about without any real research, I’m determined to prepare properly for this. I need a job, and this would be a job I’d be really proud to have, so I want to do well. As such, I figured it might be a good idea to write an article on the topic, so I can get my thoughts in order and make sure I’ve got something sensible to say, and then I can condense that down into my presentation. You know me – I tend to ramble and get distracted, so I think it’ll be good to get all that out in this article before thinking about which bits are the most important to fit into those five minutes. Plus it’s just a really interesting topic anyway, so everybody’s a winner!

So I suppose the first thing to address is definitions, since a discussion on how gamification can benefit anxiety app design immediately begs two questions: what do we mean by gamification, and what do we mean by an app for anxiety?

The second question is probably the easier one to answer; I’ll assume that everyone knows what an app is and what anxiety is, and then the rest is fairly self-explanatory. It seems to me that there are two types of apps targeted at people with anxiety: those which are directly and explicitly created and marketed as primarily solutions for the problems anxiety causes, and those which have an incidental connection and are first and foremost something other than an aid for anxiety. In the first category, we have those apps that provide features like to-do lists or mindfulness audio, software which has ‘making an anxiety sufferer’s life easier’ as its main function and selling point. Category two includes things like games which are… well, games, more than anything else, but which are perhaps designed to be relaxing or therapeutic. In other words, the second category contains apps which aren’t solely for helping with anxiety, but which might make an anxiety sufferer feel better as a sort of side-effect. We’ll be focusing on the first subset for now, since that’s probably where gamification could make more of a difference.

As for what gamification is, it’s something that’s taken off pretty rapidly and pretty extensively in recent years – certainly, it’s in the last few years that gamification as an enterprise has been formalised and recognised as a business practice. A quick Google search of the word will now turn up dozens of companies whose sole service is applying the tenets of gamification to existing businesses for various reasons, so it’s apparent that there’s (at least, there’s perceived to be) benefit to gamifying and profit to be made therein. Broadly and briefly, gamification is the practice of applying game-like elements to a task or activity which is not in itself a game. This practice in itself isn’t new; think of the Scouts, for example, who’ve been gamifying the process of learning and self-betterment for decades by awarding achievements in the form of badges to those who prove themselves sufficiently competent at a particular skill. It has, however, evolved over time, and with the rise of video games and the corresponding advent of game design as a field of study, it’s becoming both more desirable and easier to implement. Gamification is everywhere these days, as we’ll see in a bit, and its primary selling point is that it increases user engagement. You can see how that would be a benefit to a lot of industries, from marketing to education, so it’s not too hard to see why this trend for gamifying anything and everything has taken off.

So let’s say I’ve got… I don’t know, an online store, and I want to implement elements of gamification to increase motivation for people to engage with my page and therefore buy more of my stuff. What do I do? Well, I could probably stick in some sort of experience point system which rewards customers for making purchases and unlocks rewards once a certain amount of points are accrued (the customer levels up, basically). I could include achievements for maintaining a streak of visiting the site every day, perhaps, and then let the user display a badge on their profile that clearly states to anyone else who sees it that they’ve done a super-awesome thing and earned the badge. We could have a leaderboard, maybe, or even unlock premium products or discounts for the highest-levelled customers. These are just a few examples of common methods of gamification, and they’re all simple reward systems that can be added to pretty much any pre-existing business without an awful lot of hassle.

The result – in theory, although I should note that there’s not really too much doubt that, at least to some extent, this sort of thing does work – is that users feel more motivated to engage with the system and to complete the (really quite arbitrary) tasks that lead to the rewards. There is some science behind this: dopamine is released in the brain when pleasure is experienced, causing us to seek out more pleasurable experiences, and so any kind of even nominal reward feels pretty great and compels us to seek it. In fact, dopamine can even release in anticipation of a pleasurable event, so we can get that lovely buzz purely from expecting to receive a reward once we’ve completed a task. It’s a fleeting thing, though, so we’re always trying to get more of it and in bigger doses; there is, of course, a law of diminishing returns on how great something can feel, but increasing the size of the reward to keep the dopamine flowing does still work, even if it’s a quantitative increase that’s actually utterly arbitrary. After all, points that exist within a system and nowhere else don’t actually mean anything in any other context and only have any sort of relevance compared to themselves, yet getting bigger points rewards still feels worthwhile in the old pleasure centres of the brain.

Not all gamification has to be reward-based, though. That’s a pretty common way of doing it (think about any store that uses loyalty cards which accrue points and result in discounts or vouchers), but it’s not the only one. It’s probably the easiest to implement, but that’s as a result of it being the most shallow. It doesn’t require any kind of alteration to the existing system; it’s not changing something into a game, but just sticking a cherry on top of a washing machine and proclaiming that the whole assembly is now in fact a cake. The more involved methods are harder to develop because they require designing the system from the ground up around the game elements, but investing the time and effort to do this probably results in a more unified, cohesive system. This might be a good time to mention, by the way, that there are those in the business of designing actual games who refer to gamification (perhaps uncharitably, perhaps cynically, but they might have a point where less scrupulous ‘I’LL GAMIFY THIS FOR MANY DOLLARS’ businesses are concerned) as ‘exploitationware’, because it’s viewed as a way to capitalise on current trends about which the designer knows or cares little by arbitrarily appropriating gaming terminology and claiming to have made some sort of improvement. For my money, there is probably a reasonable distinction between the practice of gamification and that of game design, but I think both might have something to offer.

So what benefit might there be in all this for developers of apps for anxiety? Well, a big part of the problem anxiety sufferers face is finding it much harder than usual to complete everyday tasks or ones that usually give them pleasure or enjoyment. Apps which try to ameliorate this issue might do so by helping the person change their mindset through relaxing audio or videos, or perhaps by including a diary or to-do list which helps the person to walk step-by-step through the things they find difficult so that they don’t have to worry so much about the practicalities. What any app of this type requires in order to be effective is for the person using it to have the motivation to improve themselves, and perhaps that’s where lessons from gamification might have the greatest impact. See, people these days are finding it harder than ever to motivate themselves to do things, to engage with things, because entertainment and leisure has evolved over the last hundred years or so to be so non-stop, accessible, and visceral that we’re now surrounded by an overload of stimulation at the drop of a hat. It’s much harder now for people to feel sufficiently stimulated, resulting in a lack of motivation. This is one problem gamification might be able to help solve, adding extra features and elements to a product or service in order to increase the amount of stimulation it offers and therefore the motivation people feel to thoroughly engage with it rather than to flick through channels or browse social media on their phones while keeping only half an eye on the thing they’re supposed to be paying attention to. Increasing the motivation anxiety sufferers feel to actually get out there and do things they might find difficult in order to ultimately feel better or accomplish necessary tasks can only be a good thing, I would have thought, and perhaps including game-like elements in their treatment would help with this. Take somebody who finds it very difficult to get the bus to work because of their anxiety, for example. Changing the way they look at this task from ‘scary thing’ to ‘quest to complete’ does two things: it now feels more like a positive thing to achieve rather than something to avoid or struggle through, and it shifts the individual’s feelings to make failure seem like less of a big deal and success feel more worthwhile. It might also make the overall task seem more manageable by breaking it down into a series of achievable objectives.

This is a simple method of potentially aiding an individual with one task, but there’s more that could be done. An app could, for example, implement a social element (after all, social media is already pretty much a gamification of human interaction, what with likes and retweets providing validation and incentive to be funny or worth listening to) which might involve chat forums or leaderboards; it could offer either collaboration or competition. Achievements linked to badges could offer a tangible reward for meeting what would already be a worthwhile personal target, and this success could be easily shared with others.

Users doing the same task (or quest) could discuss their own coping strategies, and perhaps even form parties where every member gets rewarded for the group’s success, thus encouraging mutual assistance and support. In fact, implementing rewards that can only be gained through collaborative effort seems to offer several positives: those who are already doing well are encouraged to help others and work together (after all, most MMO bosses can’t be taken down solo even by the best players), while those who are struggling have an incentive to do better for their own benefit as well as that of their companions. Plus it means that people have a reason to cheer each other on, rather than to be jealous of others’ success.

Perhaps some sort of tutorial or progressive missions could also be a decent way of adding an element of fun to learning how to cope step-by-step with increasingly difficult things. Tying this to the user’s experience or level would also make the user feel that they were only ever given tasks that they had proven themselves to be competent enough to tackle, thus giving them confidence in their own abilities. Confidence is important; things like experience and levels, which can only go up and never down, can help a person to feel a sense of agency and progress and mitigate any failure. These are all game-like elements which could be appropriated onto pre-existing software, but I’m wondering whether a completely new system designed from the ground up to be an actual game and not just a game-like thing might be a better idea, if the designer has the time and inclination. Game narratives are powerful, and experiencing success in a game can make the player feel that the game’s story is about not just the success of the characters in the game’s story, but the success of the player themselves. Games can help us to change the stories we tell ourselves about who we are and what we’re capable of, something which sounds immensely valuable to a person who suffers from anxiety; the condition can make people start telling themselves that they’re useless or incapable, and that lack of belief becomes a self-fulfilling prophecy when the person then has so little faith in themselves that they don’t even try to succeed. Plus a good game is enjoyable in and of itself, with the gameplay and story being its own reward rather than something the player has to endure before getting some sort of payoff at the end. Maybe the way to go, then, would be a game about the person themselves becoming stronger and better through completing important quests. Think Pokémon Go, which is a game about catching ‘mons first and an exercise app second: sure, it promotes a healthy lifestyle, but it’s the game itself that’s the worthwhile reward, not just meaningless achievements arbitrarily tacked onto a list of tasks like ‘walk a certain distance’. This provides a qualitative reward of enjoyment and pleasure, something intrinsically fun and interesting in and of itself, rather than a quantitative and largely meaningless reward of X number of points.

There are things to beware when gamifying a real-world task, perhaps the most obvious being that it can be too easy to accidentally create an exploitable system or one which promotes unintended behaviour; in that case, the reward unintentionally obfuscates and subverts the true goal because its trigger was poorly thought-through or implemented. In other words, it’s important to ensure that the payoff is only awarded for hitting the right targets the right way. Along similar lines, and as I’ve already touched on, it can be too easy to add game features where they don’t really belong, then say ‘okay, now I’ve made it a Game and that means it’s Better’. Game elements should be added with caution and in a way that actually makes sense, a way that makes something cohesive and not some disjointed half-support-system-half-game chimera thing. It’s also important to remember that gamifying something isn’t a cure-all, and won’t automatically increase someone’s motivation from zero to a hundred percent. It can enhance motivation that was already there, and there have been suggestions that it can also improve information retention, learning and performance in tasks using similar skills, but it won’t turn nothing into something (just something into… more of that thing).

I’d like to come back to the topic of games and mental health soon, perhaps discussing how games are able to represent the experience of suffering from something like anxiety or depression in an interactive way that communicates it better than simple verbal explanation. For now, though, I think this is a reasonable introduction to the concept of gamification and how it might be applied to apps for anxiety. Now I just need to go and cut this whole topic down to five minutes, and hope I get the darn job!


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