This post was written by Tracy A. Dennis, Ph.D., who is the creator of Personal Zen, a mobile and tablet app that gamifies scientifically-proven techniques to reduce stress and anxiety. She is a Professor of Psychology and Neuroscience at Hunter College and The City University of New York. Her research examines the anxious brain, how negative habits of thinking and attention fuel anxiety, and how these habits can be transformed through cognitive retraining. Personal Zen is the first in a suite of apps that will address a range of mental and physical health issues, including stress, anxiety, depression, and addiction. For more information about her research, click here. Her blog, Psyche’s Circuitry, can be found here.
After decades of research on mental health treatments for conditions ranging from schizophrenia to depression, from anxiety to autism, our track record remains poor. For example, anxiety disorders alone will affect over 90 million people in their lifetimes — in the U.S. alone. That’s approaching a third of our country’s population. Yet, only a small fraction of us receive effective, long-lasting treatment. For many individuals, the cost, burden, and stigma associated with many evidence-based treatments are significant barriers to accessing these interventions. Thus, while we mental health professionals do much good and have some excellent, evidence-based treatments, we also know that, on balance, we are doing far from enough. We are failing.
The development of effective and low-burden interventions for mental illness is therefore among the most pressing public health needs today. Computerized and mobile interventions may have the greatest potential because they provide a qualitative leap in reducing cost and increasing accessibility of empirically-validated treatments. The potential for mobile interventions to serve as such “disruptive innovations” is strengthened by the ubiquity of mobile devices, which greatly extends the reach of psychological services to individuals who might not otherwise have access. For example, approximately 150,000,000 Americans use mobile applications on their phones and 60% use their hand-held device to access the Internet.
The Gamification of Mental Health
Growing interest has also emerged in the “gamification” of mental health treatments, in which effective interventions are embedded or translated into game format (e.g., game-like interfaces, points and rewards, and animated graphics). Gamification holds particular promise for reducing stigma and problems with treatment appeal and increasing engagement with the intervention — particularly because mobile games are becoming a common part of the daily lives of people across age groups and backgrounds.
Attention bias modification training (ABMT) is an emerging intervention that may be particularly amenable to embedding in a mobile, gaming format. ABMT emerged from research showing that exaggerated attention to threat, termed the threat bias, may be a causal mechanism in anxiety. When we experience stress and anxiety, we pay too much attention to negative information and have less ability to see positive information and opportunities in our environment. This simple habit of attention reduces our ability to cope effectively. Moreover, the selective and exaggerated attention to threat is thought to promote the continuity of anxiety by facilitating preferential processing of threat at the expense of pleasant cues or cues for safety. In other words, the threat bias is a linchpin in the vicious cycle of anxiety, in which anxious distress is heightened, attention to threat is further amplified, and opportunities for more effective coping are minimized.
ABMT capitalizes on the fact that this habit of paying attention, like many habits, is flexible and “plastic” — open to change. In ABMT, simple computer tasks are used to promote such change. Two conditions are created: (1) attentional competition is created by simultaneously presenting a threat and a non-threat stimulus; and (2) participants’ attention is repeatedly directed away from the threat and towards the non-threat by requiring a response in the location of the non-threatening stimulus. Essentially, individuals are trained to disengage from negative information and engage with positive information. A significant evidence base demonstrates that ABMT effectively reduces threat bias, anxiety symptoms, and anxiety-related stress. Combined with the fact that ABMT overcomes many treatment barriers by being brief and inexpensive, ABMT is a prime candidate for being delivered via disruptive technologies.
This increase in acceptability of the intervention is crucial because of the broad potential of ABMT as a tool for stress reduction, which has an impact beyond anxiety into the domains of the stress-related disorders and medical conditions linked to stress. The acceptability of ABMT could be greatly facilitated by the development of enjoyable, gamified versions of ABMT that are also readily accessible and affordable by being mobile.
We recently published a study exploring effects of a gamified ABMT app called Personal Zen on anxiety and stress reactivity in adults. To develop this app, we took the core components of the gold-standard ABMT protocol and designed an appealing game around the basic task-parameters while incorporating video game-like features such as animated characters, points, and sound effects. We administered a “short training” condition of the app (25 minutes with 20 minutes of rest) and a “long training” condition of the app (45 minutes with no rest). We found that a single session of the active training relative to the placebo training reduced subjective anxiety and observed stress reactivity. Moreover, the long (45-minute) active training condition reduced the core cognitive process implicated in ABMT (threat bias) as measured by an untrained, gold-standard protocol (the dot probe). Essentially, Personal Zen provides a first “proof of concept” example in which playing a game can short-circuit disruptive habits of attention and increases cognitive flexibility in order to develop new habits of attention.
We are now conducting a series of follow-up studies that use scalp-recorded event-related potentials (ERPs) to track how the app alters such neurocognitive flexibility and whether we can use brain measures to predict who may be most responsive to ABMT. In one study we are currently preparing for publication, we found that a single session of playing Personal Zen again reduced responses to a stressful situation in the lab. In addition, we added measurement of brain activity before and after play. Interestingly, we found that a single, 25-minute session of app play (compared to placebo) altered very early brain responses (between 100-200 ms) associated with controlling attention to threat. In addition, we found that males and females differed in their responses to the game, highlighting the importance of future research addressing not just whether such mobile mental health tools work, but how and for whom they may be most effective.
How Digital Mental Health Tools like Personal Zen Can Reduce Treatment Barriers
I believe that digital — in particular mobile — mental health tools can be harnessed to have profound and lasting disruptive effects on barriers to effective, affordable, and accessible mental health treatment, including the stigma of mental illness. Here are five ways I believe digital mental health tools might just save psychology:
1) If treatments are administered on a device, they are normalized
If we are successful in attempts to embed evidence-based treatments into mobile and gamified formats, I believe we can profoundly reduce the experience of and appearance of stigma. Devices have become our filters of information, our gateways to the world, sources of fun, and our hubs of connection. The actions we perform on our devices, by association, feel more “normal,” more connected to every aspect of our lives and to others. This creates a process of validation rather than shaming. By putting mental health treatments on devices, we might just be normalizing these treatments and creating positive emotional contagion — treatments become “good” by association with the devices we love. And if we gamify interventions, these effects could be strengthened even further.
2) Self-curating our mental health
With digital mental health tools, accessibility is exponentially increased. For example, with mobile mental health apps, you have affordable help “in the palm of your hand.” This ability to curate creates a sense of empowerment. This is “self-help” in a very real sense. With this high level of accessibility and empowerment, many of us will avail ourselves of interventions to reduce negative experiences and states. In addition, with the proliferation of digital tools to PROMOTE positive outcomes and to reach our fullest potential, we may find on the societal level that this positive focus is just as helpful — if not more so — as the focus on preventing negative outcomes. This attitude of promoting the positive is an excellent antidote to stigma. Who couldn’t benefit from promoting more of what is positive about oneself and how one lives life?
3) Digital health technology provides powerful platforms for community building
This is readily apparent. With greater community building comes a sense of belonging and a reduction of isolation. But digital community building also provides opportunities for effective advocacy. Of course, many such groups exist, but excellent digital mental health tools with a social media component could accelerate the creation of such systems, leveraging all the power of an individual’s full social network.
4) The profit motive will fuel innovation and valuing of consumer perspectives
Once interventions enter the digital and mobile technology world, the accompanying consumer focus (read: $$$) will force the development of consumer-oriented products. Users have power in this domain. So, if interventions are onerous, boring, or non-intuitive, people will simply not use them. User stats will do the rest — no one will put resources into a product that people won’t use. Better ones WILL be developed.
5) Digital mental health increases opportunities for gamification
The gamification of mental health is beginning. At this point, we are taking baby steps, since we have an absence of a strong empirical base; in other words, there is precious little research showing that computerized games have a direct, positive influence on mental illness or on the promotion of mental wellness. But we are only in the earliest, exciting stages of this revolution. As I’ve written elsewhere, I don’t think all treatments should be computerized or gamified, nor do I think face-to-face therapy is obsolete — far from it. But I believe that if fun can be combined with powerful treatment technologies, then we can in a single step make profound progress in erasing the stigma of mental illness and creating treatments that people will truly want to use.
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