Mental health apps: Mobile games will never be able to replace proper treatment
Turning a patient into a user won't help in the long run, even if it provides momentary relief.
A cute penguin. A millennial pink interface. 'Allies' and 'bad guys'. A new class of therapy app promises not just to help those in emotional distress, but to make therapy a fun and enjoyable experience rather than a beneficial if sometimes painful labour. That we can game our way to a vague notion of wellbeing.
How? By removing that pesky person, the therapist, and all that attends working with them, including waitlists, referrals, fees (and, of course, expert care). Instead, these apps turn the human and their mind and body into a system of tasks in need of doing and nudge the user to complete them. Once an aim is achieved (whether a task or completed module), the user is rewarded with badges and streaks, results proper to video games rather than the consulting room.
Coupled with customisable avatars and witty dialogue, apps like SuperBetter, Joyable, and MoodMission keep the patient, now called a user, coming back for more (or so they claim). SuperBetter, for instance, allows users to select their 'bad guy' that they wish to vanquish. These have a mix of the diagnostic, like 'depression' or 'anxiety' and terms from mainstream wellness culture such as 'lowering stress' or even the vague, "I’m just getting SuperBetter". The app then gives users 'quests' to get rid of the bad guy, gives 'powerups' for completing simple 'wellness' tasks, such as drinking a glass of water.
MoodMission functions nearly the same way but replaces superheroes with summiting a mountain. Based off of a series of algorithmically driven surveys that tailor the content of the app, MoodMission presents the user with five missions from 'clean your bathroom' to 'visit your favourite website'.
By replacing ongoing interpersonal therapy with a self-guided and finite quest for health, these apps provide all of the game, but none of the play necessary for deep therapeutic work to occur. And play is, absolutely, central to therapeutic process. As psychoanalyst DW Winnicott once wrote, “It is in playing and only in playing that the individual child or adult is able to be creative.” Play offers the strongest evidence that reality is not fixed. That change is both imaginable and possible.
But games (rule-bound, often driven by winning) and play (largely unstructured, open-ended) are not necessarily coincidental and sometimes are even antithetical to one another. By programming a narrow set of behaviours to be rewarded, these apps foreclose the unexpected, the creative. If a solitary training programme replaces care, as social scientist Gregory Bateson suggested, “Life would then be an endless interchange of stylised messages, a game with rigid rules, unrelieved by change or humour.” All game and no play makes us dull – even if we feel momentarily relieved.
That interactive machines might make us feel good is nothing new, nor is automating out the therapist while still claiming that mental healthcare is taking place. In the late 1950s, Dr Charles Slack fabricated tape recorders that counted how many words they recorded, and then passed them out to “teenaged gang members from Cambridge”, paying them a scaled rate to talk to themselves.
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The more they talked, the more their tallies climbed – as did their reward: cash. Slack noted that “some of the participants said they felt better for having talked this way.” Speaking was incentivised, it became a game.
Only a few years later, and across Cambridge at MIT, Joseph Weizenbaum debuted his 1966 program ELIZA, which took the idea of mechanised soliloquy to a new level. The ELIZA experiment was intended to demonstrate that “communication between man and machine was superficial.”
An early chatbot, Weizenbaum programmed ELIZA to 'parody' a 'client-centred' therapist doing a preliminary intake with a new client. Weizenbaum was in for a shock: many people didn’t quite find the interaction meaningless, even if technically and clinically it was. Emotionally, they enjoyed “talking” with ELIZA – though they knew quite well she was merely programmed to talk back – even going so far as to ask for privacy to be alone with “her”.
Ever since, and over Weizenbaum’s protestations, psychologists and computer scientists alike have worked to develop programs that might help us. In our contemporary time, these apps have taken the pleasure and novelty of re-encountering the self through the computer (or tape recorder) and combined it with our habitualised self-tracking and our current emphasis on wellness activities at the expense of deeper work and systemic solutions.
As Weizenbaum knew then, and we do now, a fleeting feeling of accomplishment is quite different from what psychotherapies predicated on depth and play offer. If we don’t think of Slack’s tape recorder as therapy, why is a reward for, say, doing a breathing exercise as an end unto itself any better? While one may feel relieved in the moment, no deep work has occurred; a bandage may stem bleeding for a time but won’t heal a patient in need of surgery.
Rigid rules and notifications demanding in-app attention (along with quests and badges) have indeed supplanted true play, and therefore also, for some, therapy. There is no human there in the program, nor human relationship, to ensure a continuity of care or to assist in playing and replaying, especially when it’s frightening or uncomfortable. These games, and their outcomes are, if nothing else, predictable, even as they might secure an individual’s participation in the scheme.
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Worse, the gamification of care is not neutral; it exists to entrain users, whether a platform delivers on its promised results or not. As game designer and scholar Ian Bogost wrote of gamification’s invention by consultants, it was: “…a means to capture the wild, coveted beast that is video games and to domesticate it for use in the grey, hopeless wasteland of big business.”
The business at hand is Big Therapy, which is increasingly lucrative. The digital health market was worth billions of dollars before the COVID-19 pandemic; now, online therapy companies are being traded publicly on the stock exchange, tele-health visits are 38 times more frequent than they were just two years ago, and employees are treated to a barrage of company-sponsored wellness reminders and initiatives while competent care has become no more affordable or accessible.
In the turn to gamification, patients are asked to consume their care and to be satisfied with only caring for themselves. The user is now solely responsible for their own wellbeing; momentary symptom reduction is the only aim. Putting the responsibility of treatment solely on the person in crisis is not just a problem of how care is delivered, but of care itself.
It’s all fun and games until someone gets hurt: these apps skirt oversight, collect large swathes of personal data, and can prevent users from seeking out full-fledged therapeutic support when they need it most. These same users are already the most vulnerable systemically to counting, data collection, prediction, and are least likely to have access to more robust, interpersonal, and, yes, playful forms of care.
We cannot praise therapy apps for their claims about expanded access and patient compliance without looking at the games they’re playing with mental health.
Hannah Zeavin is the author of The Distance Cure: A History of Teletherapy (MIT Press, 2021). She is a Lecturer of Science and Technology Studies in the Departments of History at UC Berkeley and at work on her second book, Mother’s Little Helpers: Technology in the American Family (MIT Press).