e-therapy is a mental health treatment modality that is wholly or partially delivered online, and allows for both synchronous and asynchronous communication between an e-Therapy user and a mental health practitioner. The “first generation” of computer based therapy systems were developed to replicate existing methods of therapy, for example with written treatment programmes merely reproduced to display online, and with no analysis as to how technology could improve the therapy. e-Therapy users expressed the desire to have reactive personalized content, that gave recognition to who they were, and their self-controlled treatment path. By allowing users and peers more active control in the therapeutic process, e-Therapy could encourage more positive treatment outcomes.

Gamification in e-Therapy

Game based approaches for mental health disorders are still at an early stage of development and validation. Computer based or online therapies incorporating serious game design tools have produced promising results in the treatment of depression and cognitive behavioural therapy (CBT). Serious games in this instance are the use of gaming interventions to deliver digital treatment programmes. The use of gamification in e -Therapy draws on the addictive nature of massively multiplayer online role-playing games (MMORPG’s), and relies on positive reinforcement using reward systems, which cause a release of dopamine, and promote adherence to the therapeutic game. Adherence can also be enhanced by adopting the peer reinforcement effect of MMORPG’s, where both synchronous and asynchronous social interaction can occur within the game. The feeling of connection with others holds the key to adherence in serious psychotherapeutic games.

Gamification has the potential to increase self-motivation. Reward systems such as points, badges, levels, and. leader-boards can provide interactive incentives to practice skills, and maintain adherence with the treatment programme. Interaction increases engagement, which in turn increases motivation in lifestyle intervention systems. Gamification can be viewed as a form of persuasive or motivational design, where indirect routes of persuasion invoking fun and emotion are displayed initially, with more rational content provided in a separate area, and at a later stage.

Synchronous interaction can occur in online mental health interventions by means of an avatar, a digital character that individuals can use to represent themselves, and they can control. This method of interaction is suggested as a replacement to face-to-face therapy in online or computer based applications. Therapists and clients can communicate through their virtual representative selves and deal with treatments such as anxiety disorders. Avatars can decrease stigma by allowing users to create a virtual identity, and interact anonymously.  Programmes such as Second Life, offer peer support communities, where users can interact and discuss sensitive issues.

Case Study: Silver Cloud Health

The e-Therapy programme Silver Cloud Health is a web based therapy system, which has incorporated the concept of gamification into its design. The design of the interface and the delivery style of the content creates a rich environment, where imagination, empathy, and fantasy can combine to create an immersive experience. Each user logs into a user admin area, which can be personalized and controlled. Treatment modules are displayed in a convenient manner in the user admin, with the ability to self-regulate, and design your own individual programme.

Silver Cloud Health

Silver Cloud Health User Admin. Image Courtesy of Silver Cloud Health

The rules of the “game” are explained by means of an introductory video and an intuitive programme design. Game flow is enhanced by means of easy to digest therapy modules, with clear concise goals, both minor and major, and a challenge that requires skills to master. Relaxing activities become unlocked to both provide a reward, and to alter the pace and intensity of the therapeutic process. Game flow is further optimized by an asynchronous supporter message display, to increase social interaction by means of personal support, encouragement, and reviews.  Each module begins with an introductory video with people explaining the module content, which further adds to the social aspect.

Self-motivation is addressed within the software by the design of the programme, the ability to control sessions, and the ability to set goals. The content of the programme is delivered by means of text, audio, video, graphics, and animation, which creates a positive motivational environment. Personal stories, exercises, and interactive activities are designed to encourage the user to both learn, and adhere to the programme. Self-reflection is encouraged in the programme by means of a journal and goal setting area, where both goals and mood can be recorded, and progress monitored. Within each module, People’s personal journeys with mental health are displayed along with their profile image, to encourage motivation by showing the benefits of adherence to the programme.

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