Connection, meaning, and distraction: A qualitative study of video game play and mental health recovery in veterans treated for mental and/or behavioral health problems
Introduction
Despite efforts to transform mental health care for United States (US) veterans and service members, many veterans continue to suffer from mental health problems such as post-traumatic stress disorder (PTSD), depression and anxiety (Castro, 2014). Individuals may enter service with a pre-existing mental condition (Kessler et al., 2014), and combat and deployment away from family are associated with stress and depression (Hoge et al., 2006). Substance abuse disorders are common among veterans with PTSD or depression (Department of Veterans Affairs, Department of Defense, 2015) and suicide is a pressing problem, with continuing high rates of suicide and suicidal ideation (Ashrafioun et al., 2016). Concerns about confidentiality as well as attitudinal and cultural barriers to treatment are significant challenges, and health promotion and resilience programs remain a persistent need (Hoge et al., 2015; Tanielian et al., 2008).
Trauma-focused psychotherapy is the primary recommendation for treatment of veterans with PTSD (Department of Veterans Affairs, Department of Defense, 2017). Therapies such as prolonged exposure (Foa et al., 1991), cognitive processing therapy (Resick et al., 2002), and narrative exposure therapy (Ertl et al., 2011) aim to help veterans process trauma and may involve cognitive, emotional or behavioral components, but always involve exposure to the traumatic experience. However, for many veterans with PTSD these therapies are not available or tolerated (Department of Veterans Affairs, Department of Defense, 2017). Veterans may have difficulty accessing mental health care, may fail to seek treatment due to stigma, or may leave treatment early, particularly for the most effective (yet uncomfortable) exposure-based therapies (Yoder, 2016). A wider range of mental health treatment options are needed to address the needs and barriers among veterans (Hoge, 2016). Electronically-delivered therapies may be a useful complement. The VA supports telepsychiatry visits (e.g., videoconferencing with a case manager in collaborative care models for depression or with a therapist for trauma-focused treatment for PTSD) as well as internet-delivered cognitive behavioral therapy (iCBT) for PTSD (Department of Veterans Affairs, Department of Defense, 2017, 2016). Emerging treatments take advantage of virtual reality to treat PTSD, with results showing mild-to-moderate improvement of symptoms comparable to exposure therapy and reduction of brain hyperarousal to PTSD triggers (Rothbaum et al., 2001; Roy et al., 2010).
Although goals of recovery and suicide prevention may differ slightly, both include concepts of hedonic (happiness and lack of psychological distress) and eudaimonic (returning confidence, autonomy, hope, meaning and functioning in life) well-being (Bush et al., 2015; National Academies of Sciences, 2016). Clinical best practices to promote these aspects of recovery and wellness include working with patients to identify appropriate and effective strategies—the “personal medicine” that empowers them to live the life of their choosing (Deegan, 2005; MacDonald-Wilson et al., 2013). While some strategies focus primarily on coping with symptoms, others focus on goals such as identifying and pursuing valued activities, social and community participation, recognizing strengths, and proactively managing psychological and cognitive resources (Coulombe et al., 2016; Deegan, 2005; Villaggi et al., 2015). VA clinical practice guidelines strongly support shared decision making to support veterans' recovery from behavioral health conditions (Department of Veterans Affairs, Department of Defense, 2017; 2016, 2015), and emerging practices within the VA and the private sector include online and mobile-based mindfulness interventions, PTSD coaching, therapy support, and social connection (Bush et al., 2015; Department of Veterans AffairsVeterans Health Administration, 2017; Objective Zero Foundation, 2018; Spijkerman et al., 2016). However, interventions designed to improve health often show less effectiveness in the real world due to attrition, which has led to an interest in using digital games to support mental health (Baranowski et al., 2015). This study takes a first step toward understanding how commercial video games may be used for mental health support by exploring their potential therapeutic benefits.
Because they afford opportunities for engagement and interaction, video games, particularly games involving social interaction, may be a productive way for their users to actively seek—and find— relief from symptoms of psychological stress and mental disorders and offer opportunities for users to pursue goals related to mental health recovery, wellness and suicide prevention (Bowman and Tamborini, 2012).
As a form of recreation, video games provide individuals with the opportunity to recover from stress and manage moods (hedonic benefits) but may also promote eudaimonic aspects of recovery and good mental health (Bowman and Tamborini, 2012; Reinecke and Eden, 2017; Rigby and Ryan, 2017). Aside from the fun, the challenge, the pleasurable cognitive state known as “flow” (Csikszentmihalyi, 1990), and the brief distraction from the stresses of daily life they offer as a form of recreation/entertainment, video games allow players to build cooperative relationships, engage in moral decision-making, set and achieve goals, and help others (Kowert, 2016; Oliver et al., 2015), opportunities that correspond closely to dimensions of mental health. Media use and mindfulness practices both allow decentering—psychological distancing from symptoms and stressors—which permits relief from negative moods and lifts some of the cognitive bias associated with those moods (Garland et al., 2015; Reinecke and Eden, 2017). This strategy subsequently enables a broadening of attention, which enables people to reframe perspectives and draw new meaning from difficult experiences (Garland et al., 2015). Games allow players to engage in social interactions that may enhance social and psychological well-being—they offer unique features that make them an ideal place for friendship formation and stress-buffering social support (Kowert, 2014; Steinkuehler and Williams, 2006). Even relationships with game avatars—the digital bodies controlled during play—can be useful as players use avatars to experiment with identity or work through life challenges (Banks, 2015).
Video games have been shown to reduce symptoms of PTSD (Holmes et al., 2010; Iyadurai et al., 2017) and depression (Russoniello et al., 2013) in clinical samples, and are incorporated into at least one electronic intervention for suicide prevention as a method of self-distraction (Bush et al., 2015). Young veterans with PTSD, depression or substance use disorder spend more time playing video games than those without a diagnosis (Grant et al., 2018), and a small qualitative study (n = 6) found that veteran gamers diagnosed with PTSD found playing first-person shooter games (FPS) helpful in navigating difficult aspects of symptoms and the challenges of reintegration (Elliott et al., 2015). In that study, most veterans reported that FPS were beneficial forms of distraction and helped them feel connected to others, yet also reported that at times games triggered traumatic memories. One veteran addressed the potential for FPS as exposure therapy, describing how triggering of physical symptoms of PTSD by the game allowed him to “own” and deal with these symptoms in an effective way (Elliott et al., 2015 p. 274). A recent survey study of military and veteran gamers shows that about half use games to deal with military-related stress, and those with psychological and physical limitations may seek a renewed sense of self-efficacy through gaming as a form of adaptive coping (Banks and Cole, 2016). Yet, relying on heavy use of video games to cope with stress may be a maladaptive coping strategy and lead to problematic outcomes (Kardefelt Winther, 2014; Snodgrass et al., 2014).
Recent proposals for disorders related to excessive gaming (e.g., Internet gaming disorder, American Psychiatric Association, 2013) suggest that gamers who fulfill several criteria (e.g., loss of control over gaming, continuing to game despite negative consequences, use of games to escape a negative mood and jeopardizing or losing significant relationship, career, educational or job opportunity) along with significant impairment or distress may have a mental disorder in need of treatment. Decades of video game research have focused on similarities between problematic gaming and addictions, often with significant debate about what separates excessive but non-pathological gaming from disordered gaming (Aarseth et al., 2017; Griffiths et al., 2016; van Rooij et al., 2018). Consistent with a focus on the importance of social and role functioning in psychological well-being, gamers themselves believe that interference with life areas, including avoidance of social interactions, is a primary indicator of gaming-related problems (Colder Carras et al., 2018a). Among military gamers, problematic play is not associated with loneliness or coping when pursuing positive feelings and avoiding boredom are controlled for (Myrseth et al., 2017). Clearly, commercial video games show the potential to help veterans, but it is also necessary to investigate factors that might create additional problems.
The objective of the current investigation is to broaden the scant research on the use of commercial video games for mental health and suicide prevention by examining the beneficial and problematic uses of video games in a population of veterans being treated for mental or behavioral health conditions.
Section snippets
Method
Toward a better understanding of veterans' use of videogames, we conducted an exploratory thematic analysis of both productive and problematic dimensions of this population's gaming habits. Specifically, we conducted semi-structured interviews to gather perceptions and experiences about gameplay, military experiences, and mental health in a clinical population of veterans, then analyzed interviews using thematic analysis (Gale et al., 2013). The interview guide (See Supplement 1:
Study participants' demographics, clinical and video gaming contexts
Our final sample included fifteen males and five females ranging in age from 25 to 62 (Table S1, online supplement). One participant completed only half of the interview due to somnolence from traumatic brain injury; his partial interview was included. All branches of the armed services were represented, and individuals varied in their occupations, relationship status, and domicile. Although we did not ask about inpatient status, two women and three men indicated that they were current
Discussion
We spoke with 20 veterans who played video games regularly and were treated for mental and/or behavioral health problems and found evidence linking game play to important factors in mental health recovery and positive well-being. Participants described using games to distract from overwhelming symptoms, including suicidal thoughts and drug or alcohol use, and many found social benefits, inspiration, and insight through game play. Most found games not only fun and uplifting, but also an
Acknowledgments
The authors would like to thank Major General James K. Gilman, M.D., U.S. Army (Retired), CEO, NIH Clinical Center; the Johns Hopkins Military and Veterans Health Institute; the Veterans Health Administration and the staff and leadership of a Veterans Affairs Medical Center within Veterans Integrated Service Networks 4; and our dedicated group of veteran and military advisors including James Masland, pilot, U.S. Air Force (retired); Michael Jonas, U.S. Army Veteran; Specialist Lucas Winn, U.S.
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Current address: Behavioural Science Institute, Radboud University, A.06.34, Montessorilaan 3, 6525 HR, Nijmegen, Netherlands.