PhD Research Proposal

1. Provisional Title: ​Developing Video Games for Mental Health
Topic: ​Video Games, Empathy Games, Serious Games, Gamification, Psychology, Mental Health,
Mental Illness, Mental Health Awareness, Therapy and Game-Based Intervention
According to the World Health Organization, more than 450 million people worldwide suffer from mental
illness, but unfortunately more than half remains undiagnosed and untreated, because of the stigma and
discrimination (World Health Organization, 2001).
Video games are an increasingly popular medium with 2.2 billion active gamers in the world, and are
expected to generate $108.9 billion in game revenues in 2017 (Newzoo, 2017). Video games are a
medium in the same way as books and movies, and can have different genres and can tackle different
topics, including mental illnesses such as depression. Due to their mass audience, the proposed research
would like to study how video games can be utilized for mental health.
Research Questions:
The main research question is: “How to develop games for mental health?”
There are two general types of video games for mental health: empathy games that aim to raise
awareness for mental health and destigmatize mental illness, and therapeutic games, in the form of
serious games or gamification, that aim to help people suffering from mental illness. The proposed
research would like to look into both of these types of video games.
Empathy games is category for video games that hopes to inspire players to walk a mile in someone
else’s shoes (Solberg, 2016). According to Vander Caballero, the developer of Papo and Yo (Minority
Media, 2012), in empathy games, the main experience is driven by players’ desire to understand and
relate to the emotions of other avatars or players (Caballero, 2014). Some examples of empathy games
are ​That Dragon, Cancer (Numinous Games, 2016), and ​Actual Sunlight (WZO Games, 2013),
Depression Quest (The Quinnspiracy, 2013) and ​Elude (GAMBIT Singapore, 2010) that tackle the topic of
depression.
Serious games is a type of video games that are developed for purposes other than entertainment, such
as for education, skills development or training for high-risk situations in a safe environment, including
transforming mental health services (Reynolds et.al., 2017). Some examples of serious games are ​Sparx
(University of Auckland, 2013) to treat depression, ​Champions of the Shengha ​(BfB Labs, 2017) and
ReachOut Orb (ReachOut Australia, 2016) to increases mental fitness and wellbeing, ​Secret Agent
Society​, formerly known as ​Junior Detective Training Program (Social Skills Training Institute, 2008) and
Let’s Face It (University of Victoria, 2013) to treat autism spectrum disorder, and ​Braingame Brian
(Gaming and Training Foundation, 2013) to treat Attention Deficit Hyperactivity Disorder.
While gamification is a process that leverage game design elements to motivate people in a non-game
context (Deterding, 2011). Some examples of gamification are ​Habitica (HabitRPG Inc., 2015) and
SuperBetter (SuperBetter, 2012) that applies game elements such as achievements, levels and rewards
to incentivize its users to live a better life and build resilience.
Aside from these types of games, there are also video games that contains themes of mental health, even
though it is not the main focus of the game, such as ​Hellblade ​(Ninja Theory, 2017), ​Life is Strange

2. (Square Enix, 2015), ​Night in the Woods ​(Infinite Fall, 2017), ​Celeste ​(Matt Makes Games Inc., 2018) and
The Town of Light ​(LKA, 2016).
Although not developed for mental health intervention, the game ​Journey (Thatgamecompany, 2012) has
been explored by the Games and Emotional Health Lab for its therapeutic potential and promising
intervention for depression (Gotsis, 2017).
The proposed research also have a number of sub research questions that support the main research
question.
The first sub research questions is: “​How to accurately represent mental illness in video games​?”
That Dragon, Cancer ​(Numinous Games, 2016) is about the real life story of the developers, Ryan and
Amy Green, raising their terminally ill son, Joel. Green says, “I’m not sure if everyone who has played
That Dragon, Cancer claims to have grasped what we went through, but they are now able to relate to it
in a very personal way (Green, cited in Wells 2016)”. While according to Will O’Neill, the developer of
Actual Sunlight, the game is “almost 100 percent autobiographical (O’Neill, cited in Smith 2015)”.
However, it would be difficult for the proposed research to design a game based solely on personal
experience.
For the author’s Masters by Practice, she developed a point-and-click puzzle empathy game called
Depression Simulator​. She wanted to create a game that is autobiographical but at the same time also
represents more point of views about depression, so she solicited contributions in the form of stories,
images and even music from the collaboration website ​HitRecord​. The proposed research would take a
similar approach, and look into the values provided by lived experiences.
For data collection, the author is currently developing an online platform where people suffering from
mental illness can freely share their stories in the form of writings, images, video and music. The author
will also use the platform to work closely with the community and ask for feedback and feedforward.
In addition, the proposed research would also like to work closely with experts in psychology and mental
health. Similar to ​Hellblade ​(Ninja Theory, 2017), where the main character suffers from psychosis, and
the developers worked closely with Professor Paul Fletcher, a neuroscientist and psychosis expert at the
University of Cambridge in order to portray psychosis as accurately as possible (Lloyd, 2017).
The second sub research question is: ​“How to use video games to foster player empathy for mental
health awareness?”
There are two broad categories of empathy: emotional empathy and cognitive empathy. Emotional
empathy is the automatic and often unconscious response to another’s emotions, while cognitive empathy
is intentionally taking another person’s point of view (Hoffman, 1987; Stephen & Finlay, 1999). Some
studies induce empathy in participants through experimental manipulation and compare their responses
with control groups. These studies are more generalizable to the design of video games (Belman &
Flanagan, 2010).
Belman and Flanagan published a paper in the ​International Journal of Cognitive Technology as a
resource for those interested in using video games to foster player empathy. They have also been
working on a project called ​Values of Play that is devoted to assisting students in creating games for

3. good. ​iThrive Games, ​an organization supported by The D.N. Batten Foundation and Centerstone
Research Institute, also released resources on design principles for designing empathy games. The
proposed research will test the proposed design principles by both ​Values of Play and ​iThrive Games in
the design and development of video games.
The third sub research question is: “​What are the psychological and emotional benefits of playing
video games?​”
The proposed research will look into the psychological benefits of playing video games, building upon
existing research on the topic.
CheckPoint is a charity that connects mental health resources with video games and technology,
including producing a series of videos and a compilation of papers about the psychological and emotional
benefits of playing video games.
In a paper by Ryan, Rigby and Przybylski, they looked into how games can be used to improve mood and
how the mechanics of video games can relate to the well-established model of wellbeing in psychology,
Self-Determination Theory (Ryan et.al., 2006). They conducted studies, letting participants play different
types and games and then observed their wellbeing after playing.
There have also been studies on how games can be used for relaxation, such as by observing the brain
waves and heart rate variability of players as they played ​Bejewelled 2 (PopCap Games, 2004) and
seeing how it relates to mood and stress levels (Russoniello et.al., 2009), and studying how the levels of
immersion in games, such as ​World of Warcraft (Blizzard, 2004), correlated to the player’s wellbeing
(Snodgrass et. al., 2011).
Following up the previous question, the fourth sub research question is: ​“How to design video games
for people suffering from mental illness?”
The proposed research will look into the characteristics of video games with psychological and emotional
benefits that were and were not necessarily designed to improve wellbeing, and apply those concepts in
the design of video games for people suffering from mental illness.
Champions of the Shengha ​(BfB Labs, 2017) ​makes use of biofeedback technology, in the form of a heart
rate sensor, to train players in emotional regulation (Tucker, 2017). Following its success, ​Bfb Labs is
currently developing another game to treat children with general anxiety disorder.
While ​SuperBetter (SuperBetter, 2012) is a game that is designed to help people live a better life,
including beating depression and overcoming anxiety. ​SuperBetter was validated in two clinical trials
conducted at University of Pennsylvania, and at Ohio State University Wexner Medical Center and
Cincinnati Children’s Hospital funded by the National Institutes of Health.
The proposed research would also look into the gamification of mental health treatments, such as
Cognitive Behavioral Therapy, similar to ​Sparx (University of Auckland, 2013). Sparx was developed by
the University of Auckland in collaboration with young people to teach players mood management skills in
a fantasy world where they have to get rid of gloom and negativity via different quests. Sparx has been
tested through randomized control trials and have been found to be at least as effective as treatment as
usual, and produced higher remission rates (Merry et.al., 2012).

4. Methodology and Research Tasks:
Wesley Turner et. al. published a Primer for Developing Games for Mental Health, which included a
checklist for the different stages of development: Conceptualisation, Project Planning, Developer
Consultation, Ownership Rights and Adaptation (Turner et. al., 2016). The proposed research will adapt
some of the stages of development where applicable.
While Theresa Fleming et. al. identified four key ways for maximizing the impact of video games in mental
health, namely: user-centered approaches, engaging and effective interventions, intersectional and
international collaborations, and rapid testing and development (Fleming et. al., 2017).
Review of Related Literature
The proposed research will review related literature, and analyze existing video games and projects that
focus on empathy, mental health and psychology in video games, including review existing research by
the Creative Interventions, Art & Rehabilitative Technology (CiART) of the Centre for Game Design
Research, proceedings from ​Symposium on Games for Mental Health at KU Leuven, Symposium on
Computing and Mental Health at Chi Play Workshops.
Data Collection
As identified by Theresa Fleming et. al., it is necessary to have a user-centered approach, because the
motivations and preferences of different user groups on their mental health needs are different (Fleming
et. al., 2017).
In order to cater to this, the proposed research will collect information through surveys and interviews
from people with lived experiences, as well as consult experts in psychology and mental health. As
mentioned before, the author is currently developing an online platform for data collection.
Due to the sensitive nature of the proposed research, attention would also be given to address issues of
confidentiality, such as people’s medical history, and ownership of people’s stories about their lived
experience.
Game Development
The author is proposing a PhD by project and dissertation. The project should be undertaken as part of
the PhD and not as a stand-alone project, because in order to develop video games for mental health
requires diverse skills from both experts in psychology and mental health, and video game development
(Fleming et. al., 2017), as well as significant research.
The proposed project will apply the Agile Methodology for a rapid and iterative game development
process. The stages of the game development are: Concept, Design, Development, Testing and finally
Release. This methodology is chosen because this will allow the proposed research to receive feedback
and feedforward which can be applied in the refinement of the video game. Rapid testing and
implementation is also one of the ways identified by Fleming et. al. to maximize the impact of video
games in mental health, because user expectations of video games evolve rapidly (Fleming et. al., 2017).

5. During the Concept stage, the proposed research will answer a few questions identified by Turner et. al.
at their Conceptualisation stage, such as the purpose of the game, underpinning theories for the game,
the intended target audience (Turner et. al., 2016).
During the Design stage, the proposed research will answer a few questions identified by Turner et. al. at
their Project Planning and Developer Consultation stage, such as the game genre, potential barriers that
may impede game development, the game’s expected assessment or treatment outcomes, ideas for
gameplay, essential and non-essential aspects of the game, such as narrative and level design, and
platform of delivery (Turner et. al., 2016). The psychological theories will also need to be identified at this
stage (Turner et. al., 2016), as well as how it can be translated to game mechanics (Tujinman et. al.,
2017).
Currently, games for mental health have been predominantly delivered via PC (Kharrazi et. al., 2012;
Rahmani et. al., 2012) with a small percentage delivered via mobile devices (Kharrazi et al., 2012). The
proposed research will consider both these platforms, as well as new platforms such as virtual reality.
Based on the game design, tools needed to develop the game, such as game engines and softwares, will
be identified. The scope and scale of the game design will also determine if the proposed research will
need to collaborate with other game developers, such as additional programmers, artists and sound
designers, on the project. The game will be tested and released to a test group, and iterated based on
feedback and feedforward.
In order to properly evaluate the game’s expected assessment or treatment outcomes, new assessment
and monitoring tools may need to be developed as the most intervention studies are assessed through
self-report measures (Tujinman et. al., 2017). Randomized Control Trials may also be used to measure
the treatment outcomes.
Resources Needed:
The proposed research would require a computer and softwares for development, test devices, server for
hosting the developed video games, and developer accounts for publishing the developed video games.
Potential Audience:
Listed below are examples of conferences and journals that focused on game development, as well as
the intersection between psychology and media:
● Transactions of the Digital Games Research Association
● Journal of Media Psychology
● Journal of Computer Games and Communication
● Well Played Journal (Carnegie Mellon University)
● Computer Games Journal
● Games for Health Journal
The intersection between psychology and mental health with video games is a topic that is starting to gain
more traction with the help of organizations such as the aforementioned ​iThrive Games​, ​BfB Labs and
CheckPoint,​ and ​Gaming the Mind ​by​ ​Royal College of Psychiatrists.

6. There are also a number of conferences that were about games for mental health, such as the
aforementioned Symposium on Games for Mental Health at KU Leuven, Symposium on Computing and
Mental Health at Chi Play Workshops, and Games for Change, which empowers game developers to use
games and technology to make the world a better place.
Beyond academics, the game industry and its conferences have also included talks and panels about
games for mental health, such as at Develop, PocketGamer Connects and GDC. In the independent
games community, the Asylum Jam is held yearly to challenge developers to explore outside of negative
mental health stereotypes in video games.
The proposed research will also be of interest to the general public, as it aims to use video ​games for
mental health awareness and for people suffering from mental illness.
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