While there has been increasing interest in the use of gamification in mental health care, there is a lack of design knowledge on how elements from games could be integrated into existing therapeutic treatment activities in a manner that is balanced and effective. To help address this issue, we propose a design process framework to support the development of mental health gamification. Based on the concept of experienced game versus therapy worlds, we highlight 4 different therapeutic components that could be gamified to increase user engagement. By means of a Dual-Loop model, designers can balance the therapeutic and game design components and design the core elements of a mental health care gamification. To support the proposed framework, 4 cases of game design in mental health care (eg, therapeutic protocols for addiction, anxiety, and low self-esteem) are presented.

Background: Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account. Objective: The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context. Methods: Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis. Results: Therapists used the protocol as a "toolbox" comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components. Conclusions: A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

We designed and implemented a gamified eHealth application for youth mental healthcare, to study how game design techniques could be applied within this context. This resulted in the design of a gamified mobile application aimed at supporting therapeutic goal setting: the ReadySetGoals game. The design process itself involved four key stages: (1) Identifying the transfer effect to be aimed-for, (2) Exploring the user context, (3) Designing the gamification, and (4) Evaluating the gamification. Following a preliminary evaluation, we applied a final design iteration to the app that was implemented in therapeutic practice. However, fewer therapists than expected used the app when given the opportunity and information. In a series of qualitative interviews, we investigated their reasons for not using it. Analysis of the results generated three themes that inhibit eHealth adoption: (1) Fittingness of gamification with individual users, (2) Fittingness of eHealth with face-to-face practice, (3) Distortion of therapeutic alliance by eHealth and gamification. Based on these outcomes and our design process we identified the following three recommendations to enhance implementation and adoption of eHealth in mental healthcare: (1) Align expectations of stakeholders through framing (2) Integrate therapeutic aspects in gamification, and (3) Focus on personalisation.

Different types of rewards are applied in persuasive games to encourage play persistence of its users and facilitate the achievement of desired real-world goals, such as behavioral change. Persuasive games have successfully been applied in mental healthcare and may hold potential for different types of patients. However, we question to what extent game-based rewards are suitable in a persuasive game design for a substance dependence therapy context, as people with substance-related disorders show decreased sensitivity to natural rewards, which may result in different responses to commonly applied game rewards compared to people without substance use disorders. In a within-subject experiment with 20 substance dependent and 25 non-dependent participants, we examined whether play persistence and reward evaluation differed between the two groups. Results showed that in contrast to our expectations, substance dependent participants were more motivated by the types of rewards compared to non-substance dependent participants. Participants evaluated monetary rewards more positively than playing for virtual points or social rewards. We conclude this paper with design implications of game-based rewards in persuasive games for mental healthcare.

Designers of persuasive games typically apply various types of rewards to increase the player's play persistence and to motivate the player for real world goals such as a behavioral change. In this paper, we tested if different major types of game-rewards resulted in different play persistence behavior. Additionally, we investigated if rewards were suitable to apply in persuasive games within a therapeutic context for substance dependent patients, since people with substance-related disorders have a decreased neurological reward system. In a within-subject experiment, among 20 substance dependent and 25 non-dependent participants, we examined whether play persistence and reward evaluation were affected by three separate types of rewards (monetary rewards, virtual points, and social rewards) and by player type (substance dependent versus non-dependent adolescents). As to type of reward, results showed that participants played longer and evaluated the game more positively when playing for money. As to player type, in contrast to our expectations, both substance dependent and non-dependent participants were equally motivated by rewards. Moreover, the former group was even more motivated by monetary rewards in play persistence than the latter group.

Although the potential benefits of applying game design techniques for healthcare purposes has been recognized in the past, there has not yet been much research on how such applied games could be created and used in practice. This paper presents the learnings and challenges for designing such a game from a research through design perspective. Central in this paper is the process employed to design the ReadySetGoals, a gamified mobile application aimed at supporting therapeutic goal setting within a substance addiction treatment context. The design process involved four key stages. 1) The 'transfer effect' was identified and then 2) The 'Real World' context examined. 3) Different gamification concepts were evaluated and a 'core gamification loop' was designed. 4)The ReadySetGoals was then prototyped, user tested and iteratively refined. During the design process, three key learnings emerged and are discussed: 1) Aligning stakeholder expectations though framing 2)Integrating real world therapeutic aspects in a game world experience and 3) The value of personalization.

Objective To assess the effects of a personal robot, providing diabetes self-management education in a clinical setting on the pleasure, engagement and motivation to play a diabetes quiz of children (7–12) with type 1 diabetes mellitus (T1DM), and on their acquisition of knowledge about their illness. Methods Children with T1DM (N = 27) participated in a randomized controlled trial (RCT) in which they played a diabetes mellitus self-management education (DMSE) game, namely a diabetes quiz, with a personal or neutral robot on three occasions at the clinic, or were allocated to a control group (care as usual). Personalised robot behaviour was based on the self-determination theory (SDT), focusing on the children's needs for competence, relatedness and autonomy. The SDT determinants pleasure, motivation and diabetes knowledge were measured. Child-robot interaction was observed, including level of engagement. Results Results showed an increase in diabetes knowledge in children allocated to the robot groups and not in those allocated to the control group (P =.001). After three sessions, children working with the personal robot scored higher for determinants of SDT than children with the neutral robot (P = .02). They also found the robot to be more pleasurable (P =.04), they answered more quiz questions correctly (P =.02), and were more motivated to play a fourth time (P = .03). The analysis of audio/video recordings showed that in regard to engagement, children with the personal robot were more attentive to the robot, more social, and more positive (P < .05). Conclusion The study showed how a personal robot that plays DMSE games and applies STD based strategies (i.e., provides constructive feedback, acknowledges feelings and moods, encourages competition and builds a rapport) can help to improve health literacy in children in an pleasurable, engaging and motivating way. Using a robot in health care could contribute to self-management in children with a chronic disease and help them to cope with their illness.