The Potential for Video Games to Improve Mental Health Care Access

See the Remediation

My primary audience is American counselors because they can educate the public about the lack of access to mental health care in the United States and support the use of video games to supplement such services. It is critical that this audience reads this paper so they become aware of gaming’s psychological benefits, which are less known than those of face-to-face counseling. While the latter is more popular for treating depression and anxiety, it cannot reach everyone who needs counseling, nor is it always effective. Counselors are also gatekeepers to receiving treatment. If gaming gains enough credibility from them, then they may refer it as another resource to patients they believe will express interest in and benefit from it. My secondary audience consists of families whose loved ones are unable to receive traditional counseling, as they may find video games created for therapy helpful. I hope that after reading this paper, my audiences engage in more research on gaming’s counseling potential.

I first became aware how difficult it was for Americans to access mental health care when my brother began suffering from depression. It was after our family moved to Massachusetts and he transferred to a new high school where grades seemed to define success. Because he struggled to keep up with his peers, he perceived himself as a failure and lost motivation to complete work. He eventually succeeded in getting an appointment with his school counselor, but he found it was tough for him to open up in the sessions. Meanwhile at home, he appeared to find consolation in video games like Pokémon, which lifted his spirits and made him more talkative. Was it possible that, for my brother, video games instilled in him confidence and the desire to seek out relationships whereas conventional therapy did not?

I have since learned that my brother’s story is part of a much larger narrative about untreated mental illness in the U.S. and the toll it has taken on Americans. According to the National Alliance on Mental Health, nearly one in five Americans experiences mental illness each year, but about 55% of American adults with treatable disorders failed to receive treatment in 2019 (“Mental Health By the Numbers”); for American children, that percentage was 49% in 2016 (Whitney). Many have no other choice but to engage in a trial and error approach to treatment for mental health challenges, when what is needed are innovative approaches that have the potential to more easily reach individual patients.

My brother’s experience with video games is evocative of their potential to address this issue. This paper demonstrates that video games used for therapy can help people with mild to moderate depression and anxiety cope with their mental illnesses and achieve greater independence and happiness. Since access to mental health care is difficult due to financial and geographical barriers, I also promote the use of specialty games to fulfill Americans’ unmet counseling needs. After analyzing different forms of gaming and their psychological benefits, I argue that specialty video games should be considered as a supplement to traditional counseling. While they are neither a panacea nor the only solution to America’s mental health crisis, specialized video games should be incorporated into our approaches to mental health care because they empower patients, foster resilience, and build rapport. I conclude by discussing how the U.S. can mitigate any concerns about gamifying mental health via collaboration between counselors, individuals with mental illnesses, and video game developers.

Despite strong demand for mental health care in the U.S., financial barriers to access remain. Historically, medical insurers have been a major contributor to inaccessibility because before the Affordable Care Act (ACA), they failed to provide the same level of support for patients with mental illnesses as they did for those with physical ailments. Insurance companies either denied coverage to applicants who had histories of mental health conditions or increased the cost of their premiums by 20-50% while excluding important treatments like therapies (“Mental Health Parity at Risk”). Moreover, even though the ACA lifted coverage restrictions for mental health, research shows that discrepancies still exist, disadvantaging those who suffer from mental illnesses. For example, Americans with mental health disorders still pay an average of $341 more for treatment than diabetics do for insulin (Carroll). Access for unemployed and underemployed Americans is even more concerning. Researchers at Canada’s Universities of Manitoba and Regina found that in the U.S., “low levels of household income are associated with several lifetime mental disorders and suicide attempts,” and with health insurance often tied to employment, mental health care for this group is often inaccessible (Sareen, et al.). These barriers highlight how the U.S. insurance system disproportionately raises costs of and hinders access to mental health services for Americans who may need them the most.

In addition to financial hurdles, Americans must overcome geographical ones since location determines the availability of mental health care. As of April 2020, 113 million Americans live in areas with shortages of mental health providers, with more than 60% of rural Americans residing in these understaffed locations (“Mental Health Care Health Professional Shortage Areas”). Meanwhile, over 90% of psychologists and psychiatrists “work exclusively in metropolitan areas” (“Mental Health and Rural America: Challenges and Opportunities”). This disparity indicates that millions of Americans must travel further to find a mental health professional—let alone one in their insurance network with a sustainable staff-to-patient ratio. Otherwise, some may rather visit an outside provider and pay more for quicker access to services. These sacrifices to minimize expenses and long wait times underscore that more needs to be done to help overburdened Americans receive the care they need.

Yet the growing popularity of teletherapy situates gaming as a supplemental form of treatment alongside counseling because such online alternatives to in-person services can provide much-needed support to Americans affordably and remotely. Even before people began spending more time at home during the coronavirus pandemic and playing more video games for enjoyment and social connection, psychologists have long recognized gaming as possessing potential medical benefits. Since 1975, psychologists have studied gamification—the use of recreational games and their design elements in counseling—through board and arcade games, finding that they can offer therapeutic effects to players, such as greater freedom of expression and reduced stress (Crocker and Wroblewski). The British Medical Journal’s 2012 finding that the e-therapy game SPARX was as effective as standard counseling in 12-19 year-olds with mild to moderate depression further legitimized gamification (Merry, et al.). Additionally, the emotional fitness game eQuoo gained the U.K. National Health Services’ approval in 2019, meaning that U.K. doctors can “formally refer [the app] to patients to improve their mental health” (Butcher). Along with the current use of gaming to cope with isolation, gamification shows promise in fulfilling unmet counseling needs, but unless it receives more national attention, America’s mental health crisis will continue to worsen.

Specialty games should become an aid to counseling because they empower people with depression to drive the treatment process, which can accelerate their recovery. Studies have shown that when patients believe they can control their response to depressive thoughts, they can stop the rumination that perpetuates their depression (Aggarwal). With this dynamic in mind, researchers at the University of Auckland developed the specialty game SPARX to help adolescents fight depression. In the game, players’ objective is for their avatars to restore balance to a fantasy world by vanquishing GNATs, or “gloomy negative automatic thoughts,” using “smart, positive, active, realistic, and x-factor” strategies that reframe these GNATs as healthy ones (Szalavitz). As players advance through seven provinces in SPARX, they learn more of these cognitive behavioral therapy (CBT) techniques that they can apply in real life, building confidence in their ability to better manage their depression. SPARX also incorporates game elements like purpose, mastery, and customization into therapy to produce greater improvements in players’ mental health than conventional counseling does. A study of 168 teens with an average age of 15 who had sought help for depression from youth clinics concluded that “about 44% of adolescent participants recovered completely from depression” after playing SPARX, “compared to 26% of those in regular treatment” (Szalavitz). This difference is significant because the former group played a more active role in their recovery by using coping skills they learned from SPARX to help themselves, while the latter group received support from counselors. The group of SPARX players experienced greater increases in wellbeing as well, with depressive symptoms decreasing by 30%, since they saw themselves reflected in avatars and felt more connected to their progress towards recovery (Merry, et al.). Therefore, the empowerment players gain from gaming can counter the helplessness they may feel about their depression and translate into real life results.

Besides SPARX, other forms of gaming could supplement standard counseling. Specialty virtual reality (VR) simulations such as BraveMind encourage players to persist in learning how to manage their anxiety disorders so they can focus on their happiness instead. To motivate individuals to undergo exposure therapy (ET), these systems employ a multi-level structure similar to that of commercial games. Through gradual exposure to their most distressing stimuli in-game, players train themselves to confront anxiety-inducing situations until they can voluntarily subject themselves to them in real life. This in turn helps these players realize that if they can overcome their fears, then they can regain agency and their sense of self by spending more time doing what they enjoy versus being held captive by their anxiety. Concerning virtual reality games, university studies have shown that ET is particularly beneficial for people with anxiety from post-traumatic stress disorders (PTSD). For their pilot study of the VRET system BraveMind, University of Southern California researchers studied ten Vietnam veterans still suffering from PTSD in 2001 to experience vivid war scenes closely simulating their specific traumas for two 90-minute sessions per week for two weeks. After being reassessed six months later, the veterans showed “significantly reduced PTSD symptoms,” inspiring larger VRET studies (Waldrop). A follow-up study in 2010 using brain scans found VRET to have effectiveness comparable to imaginal exposure therapy—visualizing and talking through traumatic stimuli with a counselor—through reducing neural activity responsible for flashbacks and social withdrawal that PTSD and other anxiety disorders augment (Boeldt, et al.). Such findings support that gamification develops players’ resilience by challenging them to face their anxiety while also helping them endure it and feel relief afterwards, enabling them to move on.

While complementing standard counseling, video games can build rapport as well, which enhances individual and community well-being. Research has found that commercial video games played for entertainment have similar psychological benefits to games designed for therapy because patients are intrinsically motivated to make behavioral changes when engaging in enjoyable activities (Kowal, et al.). By integrating commercial games into therapy, mental health service providers can also foster trust and gain deeper insight into patients’ emotions. For instance, family counselor Gilbert E. Franco, Ph.D., observed that playing a racing video game with his client reminded them of gaming with their late father and compelled them to open up about their grief, whereas they had not in previous sessions without gameplay (Franco, et al.). This progress hints at multiplayer games’ potential to help other clients in family and group therapy thrive, as cooperative gameplay encourages sharing versus internalization of pain, offering intervention before mental illness progresses. Furthermore, supportive connections reinforce the transfer of healthy habits in games like Wii Sports to real-world settings, while replacing risky behaviors like self-harm (Colder Carras, et al.). If implemented properly, gamification makes patients feel less alone in their struggles.

In spite of gamification’s potential to support mental health services, skeptics worry that it does more harm than good. Many parents of school-age children may fear that if incorporated into mental health intervention, gaming may escalate into addiction by promoting escapism versus progress towards achieving counseling goals (Hurst). However, gaming addiction is rare in any circumstance. Oxford University psychologist Andy Przybylski’s findings showed that only 0.3% of gamers might struggle with controlling their screen time (Judge). Even more factors mitigate risk of addiction with therapeutic gaming, which no research shows there is correlation between. Because clinicians understand the seriousness of mental illness, they screen patients before implementing this approach. Additionally, to improve the safety and design of video games integrated into therapy, therapists have suggested remotely supporting patients and adding features like time restrictions and personalized levels (Annema, et al.). Overgeneralizing gaming detracts from these efforts to align gameplay with players’ mental health objectives.

Some clinicians may also argue that gamification limits access to services instead of improving it. Psychiatrist Kalpana Srivastava and her colleagues note that equipment creates substantial cost barriers for patients (Srivastava, et al.). While devices like VR headsets are expensive, more research evidence of gaming’s potential to augment mental health care could compel the government to fund or subsidize them. Gamification eliminates other impediments to access too. E-therapy games like SPARX offer free computer and mobile versions that operate without Wi-Fi (Lau, et al.). Moreover, since most Americans own smartphones, they can access such games instantaneously, which cuts travel and wait time. Given its appeal among players ranging from younger than twelve to adults in their 80’s, gaming also engages demographics reluctant to seek traditional counseling (Barnett and Coulson). Games especially cater to people with social anxiety who prefer low-pressure environments to practice coping strategies. If patients require technical or emotional assistance, nonprofits like Stack-Up provide safe spaces to interact with professionals online and in-person, maintaining players’ rapport with mental health providers (Colder Carras, et al.). Should counselors, patients, and developers collaborate to create high quality therapeutic games, mental health services would reach even more people.

Counselors practicing in and beyond schools need to investigate and formally integrate specialty video games like SPARX and BraveMind as supplemental forms of counseling support for their child and adolescent patients because these games build rapport and empower them to manage their mental illnesses through tools that build resilience, allowing them to pursue their happiness. These patients can then use these therapeutic resources into their adulthood and recommend such games to their peers who are struggling with mental health matters. As video games have provided us with purpose, happiness, and connection even in isolation, I hope that we recognize how they can help us help ourselves and each other.