E105 - What do Video Games do to our Minds? (w/Dr. Hamilton Morrin)

Dr Hamilton Morrin is a psychiatrist at South London and Maudsley NHS Foundation Trust and an NIHR academic clinical fellow at King's College London researching neuropsychiatric disorders using neurotechnology. He is a Trustee for Gaming the Mind, a charity that promotes positive mental health within the gaming community and the games industry by raising awareness of mental health challenges and reducing the stigma surrounding these issues.

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gamingthemind.org

BlueSky/X: @gamingthemind @HamiltonMorrin
Interviewed by Dr. Alex Curmi, consultant psychiatrist and a UKCP registered psychotherapist in-training.

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Transcript

  Same way. And are video games good or are they bad ? Are films good or are they bad? There are so many films that are awful and some incredible films. Same with literature. There is some atrocious stuff out there, but because video games are such a nascent form of media and field, comparatively speaking that have, they have been around for a while, I think people are a lot more comfortable asking these kind of questions, and I think it is important to acknowledge that. 

Obviously there's a lot less history there, but it's grown incredibly rapidly. Like any art form, video games can move us, they can inspire us, and they can transport us to another world, another set of experiences. And perhaps maybe even unique to video games can let us become something or someone else for a period of time. 

Welcome back to the podcast. Today we're talking about video games, a subject that when discussed in relation to [00:01:00] mental health, often has quite a negative connotation. But with us to discuss this today is Dr. Hamilton Moran. He's a psychiatry trainee in the South London and Maudsley Trust, and he's the lead and trustee for Gaming the Mind, a UK charity focused on the overlap of mental health and video games, and focused on how video games can be used positively and productively to actually improve people's mental health. 

So today on the podcast, we discuss how video games can be beautiful, In what way they are a valuable art form, what makes a great video game, how video games can be beneficial for mental health, but also some of the downsides, and what might characterize something like a video game addiction, and the relationship between video game addictions and other addictions. 

We also discuss some more esoteric subjects, like the so called predictive processing model of the brain and how that can help us explain the difference between sensation and perception, and the uses of [00:02:00] things like VR exposure therapy for treating people's fears and phobias. This is the Thinking Minds Podcast. 

A podcast all about psychiatry, psychology, self development, and related topics. As always, I hope everyone's doing well. Thank you so much for listening. And here's today's conversation with Dr. Hamilton Moran. 

Dr. Hamilton Moran, thank you so much for coming on the podcast. Thanks for having me, Alex. Dr. Alex Kermy. It's a pleasure. What do you think are the elements which make for a really good video game? Oh, that is a question that I think the games industry has been looking to answer for a long time and arguably has answered in many ways. 

It's a, it, ultimately it all comes down to fun, right? It has to be enjoyable. It has to be, It has to be satisfactory. And sure, you can have a good story. You can [00:03:00] have themes that are important and relevant for our society. However, if when you jump, it doesn't feel like you're jumping, or if you pull a trigger and a gun, it doesn't feel like you've done so. 

It feels a bit floaty and iffy, then it takes you right out of it. And that ties into another theme of immersion, which is relevant to fun and quite related. It does come down to fun, ultimately, I think. But the thing about video games is, of course, it's not fun. It's not a benign fun. I'm just having a really good time. 

I'm really enjoying myself. It's more of a, it's a fun of trying to accomplish something. Like, in a game, strangely enough, you're trying to accomplish a goal, you're trying to improve some sort of skill, you're trying to get better. So, I guess what I'm asking is, how is it that video games often entice a lot of people to spend a lot of time working really hard to achieve something? 

where they might find it [00:04:00] really hard to put in work outside of video games. So what's enticing about them in that sense? Ah, so you've, I think, hit the nail on the head there, with regards to the idea of achievement and reward, and the approach that video games can take. And it's important to specify that Many video games are, there are many different approaches to designing a video game, but we do know that there are many video games that do make use of, let's say, behavioral psychology approaches that are akin to the idea of operant conditioning. 

Yeah, and With operant conditioning, there's a number of approaches you can take but the most classic example would be say you have a box and There's a mouse in the box and let's say every time the mouse presses a lever it gets some food so that would be the reward and You could have it so that every time the mouse presses the lever it gets a reward of [00:05:00] food and that's regular interval rewards, right? 

Every time it presses it or there's a consistency there. As opposed to a process which is a lot more rewarding, which is if sometimes when the lever is pressed, there is no reward. But sometimes there is, and it's almost random. We know that this actually is more likely to reinforce repetition of that behavior. 

And so let's take two analogous video game examples. Say you have a skill tree and you know, every time you reach the next level, you'll unlock some more skills. So that's quite clear. It can still be enticing. It can still be reinforcing, but you more or less know what you're getting out of it, you know, regularly. 

However. When you introduce randomness, when you have, let's say a mechanic where you can perhaps spend some money, whether it's money in the game or money in real life for a chance, not a guarantee for a chance. [00:06:00] of maybe getting a new skin, a new weapon, and a new character. You can see how that suddenly sounds a lot like something else, doesn't it? 

It sounds a little bit like gambling, which we know is a common behavioral addiction. for many people. And I want to specify not all games use these kind of approaches, but by and large, actually, when you look at the mechanics of many games, sometimes for some games, you start to think, gosh, this is a bit familiar, a bit similar to a Skinner box. 

Yeah. Why do you think we have that baked into our psychology, this vulnerability to the allure of an unpredictable reward? Why, why do you think we have that as part of our mental software? So I guess at this point we'd have to delve into the realm of evolutionary psychology, where there's a lot of postulating. 

There's a lot of hypotheses that, and which we go with because it [00:07:00] vaguely makes sense, hard to test them, of course, but I'm still a big fan. And I suppose ultimately. If we cast our minds back to actually evolutionary speaking in the scale of time, we haven't our brains and haven't progressed that much from when we were foraging, scavenging, and hunting really as a species. 

And so one can see how perhaps when something is unexpected, when something is a surprise, there salience. It's important that we pay attention to something that is surprising and unexpected because ultimately it's outside of what we've predicted. And it's new information. It's new information that we need to incorporate somehow. 

It could be helpful. It could be detrimental. It could be new information signifying a threat or a source of food. And. When one starts to get into the idea of, uh, and really delve into the [00:08:00] rabbit hole of predictive processing and how actually everything that we experience. And there's a school of thought and it relates closely to ideas of computational psychiatry and philosophy as well. 

But we're predictive processing, uh, models of, of mental illness and the phenomenology of consciousness, for example, there is the idea of. Actually, it's, classically, we like to think of consciousness and everything we experience as being the result of our senses, our bottom up sensory experiences feeding into our brain, right? 

That's wrong. That is wrong. Actually, If you've ever experienced a visual illusion, like the mask illusion, where it looks like it's convex, but it's actually concave. Or the chessboard, where you predict because, oh, because of the positioning, this is going to be a darker square. Actually, the majority of what we experience is a result of our brain's predictions about the world around us. 

And they are updated when there are [00:09:00] errors in those predictions, when we come face to face with this novel, unexpected information. And this is largely happening unconsciously. Absolutely. Yes. If it were conscious, problems may arise, right? And one can think of the example of overthinking something, trying to park your car, you're trying to parallel park. 

Oh gosh. Now I'm suddenly thinking about how I place my foot on the accelerator and oh gosh, there's people behind me. And you start to over process, over thinking, overdoing. So is the idea of predictive processing, essentially the idea that, you know, Our minds are always unconsciously trying to predict what's going to happen next and or what we're going to perceive in the sensory environment and is always comparing what actually happens to our expectations. 

Is that a good way of summarizing it, do you think? One thing I do want to emphasize is it's not just a prediction of the future and near future, but actually it's also a prediction of the now. Right of the present of the immediate [00:10:00] that makes sense. Yes, hence why a rubber hand illusion works where you cover up a person's real arm and you have a rubber arm and you stroke both arms at the same time with a Feather and then you hit the rubber arm with a hammer and they feel that real pain There's that prediction of there should be pain right now yes, and I use this idea to try and explain the difference and I really like this distinction between sensation and perception. 

So in my mind, sensation is the raw sensory data that goes, that we get into our bodies and minds, raw visual data, tactile information, olfactory smell information, whatever. And perception is the outcome based on getting that sensation, getting that sensory data, and also comparing it with those expectations in real time, such that what most people think are sensations are actually perceptions. 

So you think you're seeing something, but that's already filtered out. [00:11:00] That's already a filtered sort of processed version of what you've sensed. And now it's a perception. And perceptions also include layers of meaning and what, not only what we're seeing, hearing, touching, but the meaning we make. And so I find that distinction really helpful. 

Absolutely. And it's a helpful model, I believe, for understanding our everyday experience of consciousness and just day to day life. But actually it's also really helpful, I believe, for understanding mental illnesses. And through the model of the brain and the mind as a prediction machine, one can see how actually there's not that much that sets apart neurological and psychiatric illnesses. 

It's just a matter of which system has gone wrong. Is it specifically motor function? Is it a breakdown in our predictions about the world around us and our own bodies? It's, it's, I think, quite a neuropsychiatric approach. So could you give me an example of [00:12:00] how we can use this distinction of sensation and perception or this predictive processing model to help us understand, for example, someone with depression or anxiety or a mental health condition of your choice? 

Sure, and I think, let's use the example of anxiety and depression, because we know within a CBT framework, cognitive behavioral therapy approach, there are certain cognitive distortions that people can experience when they're depressed or when they're anxious. And actually, when you break down some of these distortions, often they are examples of predictions gone awry. 

There is the idea of, uh, mind reading. The hole people fall into where you assume that you know what people around you think about you, your colleagues, your friends, your family, and that can really affect you mentally, emotionally. I think that's just one example. I mean, I think people should read all about cognitive distortions because it's [00:13:00] basically a manual. 

of how your mind goes, or I, and most people suffer from most cognitive distortions, unless they've really looked at it. In terms of the work I'm doing for my upcoming PhD, I've been looking a bit more at kind of functional disorders, previously known as conversion disorder, where at the moment, latest conceptual models frame it as a rising secondary to predictive processing errors within a kind of a Bayesian model. 

And so for example, rather than we know, rather than there being a structural change to the neurological system, which results in say a physical weakness, rather it's a breakdown in kind of the communication between say the mind and the body. And it can be perceived as a misattribution of agency, right? 

So perceiving involuntary movements as voluntary, or on the other hand, perceiving voluntary movements as involuntary, say with a functional tremor. And so Professor Mark Edwards and [00:14:00] others have really championed this framework for understanding functional neurological disorder because historically there's been perhaps, and many patients with functional neurological disorder have voiced that they, there has been a feeling that historically there's been an over assumption that it's 100 percent repressed psychological stress. 

It's 100 percent psychological. But in reality, we know it's actually, it's more complex than that. And we know that yes, people with functional neurological disorder are more likely to have comorbid mental illness. And we know that there is more likely to have been a history of traumatic events. However, it's not always the case that there is some sort of unspoken trauma that, that needs to be processed. 

And actually people can experience quite severe functional symptoms almost out of the blue, where there is this kind of breakdown And there's this prediction. I, and it, what's interesting is often patients won't act. Some patients won't use the word weakness. They won't say my arm is weak. It's I can't move it. 

I cannot will. So it's interesting that kind of that [00:15:00] difference in manifests as weakness, a motor sign, but then actually our understanding of actually how it likely arises due to this breakdown in. the minds and I, I'm going to use the mind and brain interchangeably a lot here. And I'm sure you do too on the podcast because we're not Cartesian, are we? 

We're not dualists. Yeah. But you see how there's this breakdown in predictions about the, the, the body as well. And I think the, the Cartesian breakdown, like, the idea that there's a split between mind and body is a source of a lot of the controversy within the functional neurology world, you know, people who have a conversion disorder or functional neurological disorder, which just for those who don't know what that looks like is a sort of sudden, unexplained problem like, you know, a limp of your arm where your arm doesn't really function. 

And again, like, as you said, you feel like you can't move your arm or something along those lines. And it seems like there's this kind of unhealthy debate that some people feel it's [00:16:00] all psychological and all due to repressed psychological problems. As you said, some people say that there's clearly some sort of biological process underpinning that. 

Really, if you look at anything within the mental health world, what we're seeing more and more is this very complicated mix of biology and psychology interacting in a way that's, it's even hard to tease them apart. And I find there's a lot of, um, maybe unnecessary animus on both sides of the debate somehow. 

I think when we say there's a, there's a psychological underpinning, people with functional neurological disorder often feel like that's invalidating their experience. And I've actually interviewed people on the show who, who talk about the psychology, and we've got a lot of negative pushback about that. 

But I think the psychology is important. Similarly, I don't think, I think the biology is important and the more we unravel those mysteries, I think that's important, but I think, I don't think there's anything special about [00:17:00] biology that somehow validates a problem in a way that psychology can't. That's not how I see it, but that seems to be how a lot of people react. 

Absolutely. It's a, an area that the number one thing is always, of course, working with patients, with people with lived experience and understanding their preferred approach and, and the use of terminology. And, but we do know in terms of the evidence base that it is important incorporating the entire MDT. 

We know that there are patients who benefit from physiotherapy, from talking therapies, from the input of a neurologist, a psychiatrist, and it would be a disservice to patients to just reduce them to one camp for the purpose of an ideology, as it were. So getting back to video games, if you look in the media about video games and mental health, what I would expect is you'd mostly find things which are quite negative and suggest that video games having a negative effect on people's mental health, perhaps especially young men, and perhaps [00:18:00] these video games designed by game designers to be particularly seductive in ways we've described, uh, could be taking a lot, a lot of people's attention and perhaps maybe even predisposing them to mental health difficulties. 

But what, what would your response be to that? You obviously work with Gaming in the Mind, a charity which is all about helping gamers and even seeing how games can be used in a more productive way. So what would your response be to, to, to the sort of negative skew that video games tend to have in the media? 

So I think. In these matters, it's always important to refer to the literature and what studies have been conducted on the effects of playing video games. I think I should probably address the elephant in the room, in that a lot of interest of the effects of video games came from a place of moral panic in the 80s. 

One remembers when Mortal Kombat came out and there have been several cases over the years where there's been, say, a tragic incident and someone [00:19:00] looks on the hard drive of individuals involved and it turns out they played a video game. But correlation is not causation. And to be frank, there's not even correlation. 

Video gaming is an incredibly common hobby. Now it's an industry that last year it was worth 190 billion. The old school stereotype of it being just, just guys and just kids and teenagers is completely false. Actually, we know there's a very close split about 46 percent female, 54 percent male. And we know that it's not only a large industry, but it's a rapidly growing industry. 

And that. It's not just children and teenagers that play, but people of all ages, with the largest groups actually being those between the ages of about 25 35. So, I think it's important to acknowledge that, and that a lot of the initial early research on the effects of gaming, I think was driven from a place of position of moral outrage and fear. 

And it is important, of course, [00:20:00] to question if we had any form of media, where many individuals are spending a lot of time on it, you know, what is the effect of this? It's important to question that. At the same time, it's also important to acknowledge that maybe sometimes we've asked those questions of gaming in a way that we haven't asked of other hobbies. 

Like television watching, social media usage, exercise. As with anything, you know, all things in moderation. Anything can be detrimental at a certain level, at a certain point. But I digress. There's actually been, despite for many years there being a lack of good quality evidence and research, there's a group of researchers in Oxford at the Oxford Institute, Internet Institute, led by Andrew Przybylski. 

Who've done quite a lot of research on the effects of screen time where by and large they found a bit of a Goldilocks effects actually where there's a sweet spot where a certain amount of screen time improves your well being and satisfaction generally in life. Go past that it [00:21:00] deteriorates, but funnily enough, if you're below that sweet spot, it's also lower. 

And then it makes you think, who are the kinds of people that aren't using screen time? A mobile phone or a computer, are they undergoing a lot of stress? Can they not afford it? An interesting question. So that's screen time in general, but this same group has done a few studies, most notably one published in 2021 and one published in 2022, where they looked at really interestingly, gameplay time data, as well as survey results regarding people's wellbeing and satisfaction. 

And with the first study published in 2021, which was during, well, y'all, there was something that was happening around that time, I'm sure you'll remember Alex, yeah, yeah, I think I remember. But for the first paper, they surveyed about two and a half thousand individuals who are playing two different games. 

Animal Crossing was one of them and the other one I can't recall. And for that study, they found that a general positive correlation with well being when looking at how long people live. played. They then did a second [00:22:00] study which was much larger and they looked at real time gameplay data across seven different games of varying genres ranging from action, real life sims, racing. 

So seven different games with 40, 000 individuals and I have to say this study has to be praised because it's quite rare to get video game companies to agree to share that kind of data on play time. So it's a nice step forward an example of where we can go next in terms of research in this area. And ultimately, they concluded that there was no correlation or relationship with well being between screen time, neither in a positive or a negative direction. 

And, of course, it's important to note that, apart from the larger sample size, the second study didn't take place during the COVID pandemic, which we know, obviously, heavily impacted upon people's well being and their playing behaviour, their hobby behaviour. Now, more recently, and feel free to stop me by the way, at any point, uh, but more recently, just this August, there was a paper published in Nature Human, uh, Behavior in [00:23:00] August. 

It was a study of game behavior between 2020 and 2022 carried out in Japan. It's a really cool paper because it's, it was really lightning in a bottle. There's probably never going to be another chance to run a naturalistic experiment like this, but essentially the idea behind the study was that in Japan during the pandemic, and obviously this wasn't just the case in Japan. 

In many countries, it was difficult to get new game consoles. There was a lot of demand for obvious reasons. And. In Japan, there's a tendency when things are not very available, for the sake of trying to make things more accessible, they often give things out in a lottery. There's a lot of stores that do this. 

It's an interesting process. And they had a lottery for winning video game consoles. Nintendo Switch or a PS5 and they looked at psychological ratings of psychological distress and general satisfaction and they found, to cut the long story short, they [00:24:00] did find that there was a bit of a relationship there between play time and general reduction in levels of distress and overall satisfaction. 

Of course these, whilst there were significant effects, it's important to note that the scales used were kind of like general scales of well being, not really clinical tools that we'd use and Arguably differences weren't clinically significant. So I think the main takeaway generally is if people have a hobby and an interest and you let them engage in that recreational activity or hobby, they're probably going to be a bit happier about it, but that isn't to say that there aren't individuals where, forgive me for using a terminology that I think is used in other areas, but at a certain point the fun stops and it's important to know that this is a vast minority. 

This is a very small group of individuals. If you look at the number of people overall who do play video games, but there are some people who do experience problematic gaming behavior. One thing I do want to mention before I forget [00:25:00] with the, um, 2022, Andrew Shabelsky Oxford paper, where they found no effect, they did find that when they did sub analyses, that what rather than game time, the amount of time you spend playing a game being related to, to markers of wellbeing, the motivation for playing the game was important. 

Not massively, but there was an effect, which I think is really interesting because you have this idea of if people are intrinsically motivated to play a game, if they want to, if it gives them some sort of fulfillment, if it's a hobby, then of course, that's going to be associated with improved wellbeing. 

As opposed to extrinsic motivating factors. I have to, I'm FOMO, I'm going to miss out on this time limited event, or I just need to, it's like the team is relying on me and I don't necessarily want to play, but I have to, and I think that's an interesting concept and idea that probably can apply to several different areas, intrinsic versus [00:26:00] extrinsic motivation. 

Yeah. I think when, when you're considering the risk of addiction, it's never, just the thing itself. It's always, the question is always, what's your relationship to that thing? So if you picture a nice cold bottle of beer, you know, one person's relationship to that might be, I have, I have one once or twice a week. 

I have one when I'm celebrating, I've worked really hard all week and I'm going to have this to let off some steam. Another person's relationship to that very same object might be, well, it's what I drink when I wake up first thing in the morning because I need to. And I'm sure video games are the same in that if you use them because they give you joy, because they give you recreation, a way to communicate with your friends. 

Sometimes even a way to make friends and form new relationships. Then I imagine it would increase someone's well being. Uh, at the same time, if it fills some sort of more compulsive needs, perhaps an emptiness, [00:27:00] difficulties that someone's having in their life. And this is more of a, an escape and a way of not dealing with, indeed of avoiding the certain things. 

then perhaps we're in more addictive type territory, but I'm sure this is something you see all the time in people that you work with, people who you contact via Gaming the Mind. Is this a tension that you observe often in that world? So, I think it's important to identify that as a spectrum, right? You have regular gaming, At a certain point, you have, let's say, gaming is one of your main activities that you engage in, and that might still be fine, there might be a social context, it might give you a lot of sense of purpose, a sense of identity, it might be quite fulfilling, but then there is a certain level where it reaches, I guess what could be termed problematic gaming, where you start to prioritize it over, other aspects of your life to the detriment of other areas of your life, relationships, friendships, family, [00:28:00] work. 

And I guess the end of the scale is something, there's two terms in two different diagnostic criteria. And I'll go through, let me walk you through the history. So back in 2013, with the release of the DSM 5 disorder, internet gaming disorder was included and it was included as a condition requiring further research, but included nonetheless. 

And the exact terminology that they used was that the proposed symptoms of internet gaming disorder would include preoccupation with gaming. Withdrawal symptoms when gaming is taken away or not possible. Interesting, withdrawal. Tolerance. The need to spend more time gaming to satisfy the urge. An inability to reduce playing or unsuccessful attempts to quit gaming. 

Giving up other activities. Loss of interest in previously enjoyed activities due to gaming. Continuing to game despite problems. deceiving family members or others about the [00:29:00] amount of time spent on gaming, the use of gaming to relieve negative moods such as guilt or hopelessness, risk having jeopardized or lost a job or relationship due to gaming, and ultimately it was proposed that someone would have to experience five or more of these symptoms within a year and it could include gaming on the internet with others or alone. 

And so this was the first version of gaming disorder. Interesting. And I'd be curious to hear your thoughts about the withdrawal symptoms, use, because withdrawal is an interesting term. And it might mean that different things to different people, but often when clinicians talk about withdrawal, they often think about the physiological withdrawal that you might see with drugs or certain substances rather than behavioral addictions. 

Um, and so that arguably is something that could be, um, uh, I guess, open to interpretation of the term withdrawal. I don't know what you think about that. I mean, my, my thoughts on the withdrawal is that the [00:30:00] most likely explanation for a sense of withdrawal for related to overuse of video games would be dopamine. 

Dopamine desensitization. So, very briefly, and this is really explained well in the book, um, dopamine Nation by Anna Lemke. I've talked about this book a lot on the pod, on the podcast. Anna was on the podcast, uh, last year. Um, but the, the gist is that highly stimulating things cause the release of a lot of dopamine. 

If you do that for a really long time and then you suddenly stop and you just, you know, go about real life. to be much harder to get sort of the release of dopamine that you would normally get say watching the sunrise or meeting your friends or eating a tasty snack and that like lack of happiness, that sort of blunting of normal pleasurable stimuli can be perceived as a kind of withdrawal syndrome or a feeling of withdrawal. 

So that's, that's, that's, That I think is the most likely explanation. Does that make sense to you? Yeah. Yeah. And I [00:31:00] think generally speaking, that would make sense in the context of most behavioral addictions. And I guess it's, but there's part of the issue is whilst there are some studies that do, in fact, we, in our journal club, gaming the mind journal club, I think earlier this year, someone did present a paper that did do some dopaminergic functional neuroimaging in individuals who were diagnosed with gaming disorder. 

But actually the, basically there's not a lot of. research evidence yet. It's a lot of postulating and it's theory, but we don't have a lot of evidence yet at this point. The fast forward five years and we have the ICD 11 from the World Health Organization. And in there they introduce gaming disorder, which they diagnosed, they, they define as a pattern of gaming behavior, digital gaming or video gaming. 

characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily [00:32:00] activities, and continuation or escalation of gaming despite the occurrence of negative consequences. And for gaming disorder to be diagnosed, the behavior pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, Occupational or other important areas of functioning and would normally have been evident for at least 12 months. 

And this is arguably perhaps a bit better or a bit less contentious than Internet Gaming Disorder, the definition provided by the DSM 5 before, which made reference in terms of withdrawal. And actually the ICD 11's definition of Gaming Disorder does borrow quite heavily from the same terminology for Gambling Disorder, for example. 

Which is the behavioral addiction that we probably have the most research on, though it's not the only one, of course. And as of 2019, the UK actually has a gaming disorder clinic, which sees patients from all around the country. And this service was set up to [00:33:00] mirror existing gambling addiction services. 

And as of 2023, there are. been referred about 745 people, which is more than zero. But at the same time, I think interesting in terms of numbers, because some people would have you believe that gaming addiction is destroying society and whatnot, but actually these individuals do exist and do require help and support. 

But actually it's probably a lot, it's quite overblown and a lot less common than one would think, but they accept self referrals and referrals from family or health professionals. And a big part of what they do is screen for other conditions, such as anxiety or depression, where the gaming. May being used actually as a support mechanism, uh, as a bit of a crutch and my understanding and to clarify, I don't work with the service. 

I do know some clinicians who do. And I understand that rather than promoting a model of completely cutting out gaming, they actually do a lot of work around harm reduction and getting people back to a certain level of functionality, which we know there's a lot of good evidence for, for many addictions rather than a [00:34:00] model of kind of completely stopping and going cold turkey as it were actually, it's a lot more realistic to try and do that. 

get people to a healthy level again, where they can function, so to speak. Yes. So what do you, what do you think in your experience are the benefits of playing video games? You know, not from the research to just from your experience and from the experience of your community. Yeah, I think games are a fascinating medium. 

Like any hobby, video games can engage us, they can distract us, they can really tickle our brain, they can affect our mental state, like a moving film or an entertaining read. Like any form of media, video games can tell stories, they can depict personal journeys, and sometimes even personal journeys with mental health. 

We've seen games like Hellblade, Senua's Sacrifice, which have an incredible depiction of psychosis where they work together with people with lived experience and clinicians and [00:35:00] researchers to have an accurate depiction. One fight bath does that game. And like any art form, video games can move us. They can inspire us and they can transport us to another world, another set of experiences. 

And perhaps maybe even unique to video games can let us become something or someone else for a period of time. And I think. A big deal of what people get out of video games, for some people, there will be that escapism element. There will be being in a new environment, having these new experiences that perhaps aren't necessarily accessible in day to day life. 

There's not just doing things that aren't accessible, but doing things that are impossible in day to day life. You can't exactly ride a dragon or go to the bottom of the sea, but video games make that possible. At the same time, I think there is very much a, uh, A sense of achievement that many people get through with games and a sense of mastery, and this can come in various shapes and forms. 

This can be [00:36:00] actual mastery. This can be developing hand eye coordination and getting better at your reaction times and surviving longer in a combat situation or getting better at racing around the track or down a snowy mountain, or this could be, let's say, simulated achievement. where you're playing a role playing game and perhaps simulators is a bit unfair because there is something to be said about completing a game and dedication and patience but sometimes in some games it's more a matter of repeating tasks or getting points which simulate growth which simulate literally experience points where a character can level up and unlock new abilities and skills and there is progression but it's not it doesn't you don't necessarily have to get better the game In some of these games, maybe in certain soft ways and certain knowing the best places to go or getting good at identity or teaming up with other players, perhaps, but I think it is important to draw a difference between actual [00:37:00] development of motor skills, cognitive skills, as opposed to. 

So you're, you're saying there's a distinction that some games actually really help to improve motor skills, visual, spatial skills. thinking and problem solving and perhaps some games less so. Yes, in the same way, and are video games good or are they bad? Are films good or are they bad? There are so many films that are awful and some incredible films. 

Same with literature. There is some atrocious stuff out there. But because video games are such a nascent form of media and field, comparatively speaking, though they have been around for a while, I think people are a lot more comfortable asking these kind of questions. And I think it is important to acknowledge that Obviously, there's a lot less history there, but it's grown incredibly rapidly. 

Everyone loves the classic example of studies of comparing, I think, endoscopists and laparoscopic surgeons who play video games to those who don't. Obviously, if you have a bit more experience with that kind of 3D visuospatial navigation, it's helpful. So is that true? Is that, is that confirmed that if you Have a history [00:38:00] of playing video games. 

You are better at things like laparoscopic surgery. So there are papers, whether or not that makes it true is open to debate, but there was a paper published two years ago where it was more of an experimental approach where they allowed people to play a video game rather than took people with a history of playing video games and compared performance in an endoscopy task. 

And there was an improvement with this. I guess you could consider it practice of free 3d. Visual Spatial Navigation in a simulated environment. I'm pretty sure there is also a one that looked at history of video game use, but I'd have to get back to you on that on the exact citation, but yes, it's interesting as well, the idea of using video games for a form of brain training and that there are some people putting a lot of money into this and people who really believe in it. 

For example, there's a game called Endeavor RX. I don't know if you've heard of it. It's a game which is FDA cleared. Which I want to emphasize is different from FDA approved, but it's FDA cleared. [00:39:00] And it's meant to be a game that allows attentional training specifically for children and young people with ADHD. 

And there was a publication in translational psychiatry this year where they looked at the benefits in terms of. improvements in performance within the game, which was their kind of measure for cognitive improvement. But then they also did use an ADHD scale, which is used in the literature. I've not seen it used clinically, but the Tover scale. 

And they did find that people who spent time playing this game, which demands certain levels of attention did have improvement in their ADHD symptoms and reportedly quality of life. I have to say there were some limitations and issues with the paper, but there's no perfect paper. And one thing that I do want to emphasize is that The term video game is used. 

Um, but I find increasingly in research, many people are calling things video games, someone wouldn't buy in a store. For example, a kid wouldn't specifically choose the spend time [00:40:00] on this. Rather, it's more of a continuance performance task where they've created some nice, nice user interface and nice like 3d visual graphics, but you're essentially on rails and you're having to move from different tracks as a test to make sure you're still paying attention. 

And. That's sure. I think it's interesting whenever someone makes an app or a game for a clinical purpose. If you can encourage people to keep using it, sure, that's great. But I think there is, it's important to be aware of the difference between serious games, which are games that are developed specifically for research and clinical use or to educate and commercial video games. 

Everyone wants to have a game because it's cool, it's, it's appealing, but not all games are equal. And I think it comes back to that first point of it has to be fun, or at least there has to be, there has to be a form of entertainment that you get out of it, some sort of fulfillment, rather than just playing it to better yourself or to learn something. 

Yeah, and I suppose there's a [00:41:00] tension that emerges there as well between commercial video games and more, quote, series video games and that. Yeah, maybe the more serious ones have a specific use that can be elucidated and that can be very helpful, but ultimately in terms of the art form moving forward and, and demonstrating real beauty and real immersion and the ability to really, you know, positively impact someone's life in a sublime way, it's going to happen in the commercial space. 

It's not going to happen with that more intentional design. I think really good intentional designs can then come out of advances made in the commercial space. But the commercial space, just like with film, just like with literature, is where you're going to get things moving forward in a big way. That's paradigm shifting, if you like. 

Absolutely. It's, we connect with, it's art, right? It's, a story is put out there and it feels, let me get this right, it's the difference between reading a novel and reading a textbook. You can learn [00:42:00] a lot from a textbook. You can, I don't know anyone who said a textbook changed their life, maybe, but there's something about, fiction or something about art where it's the human element, it's the connection, it's the purpose itself is for fun. 

And I think, if I'm not mistaken, in a recent podcast, Alex, you referred to play as brainstorming of your body, like the process of play. And I think there's a lot of truth in that. And I think it's interesting that play isn't, isn't, Exclusive to humans, to us, many species play, and often many species play fight. 

And play can be almost a healthy environment for rehearsal or mirroring of real aggression, of real conflict in a safe arena. Arguably, global sports is just that. It's a healthy environment for competition between various nations that doesn't involve loss of life and tragedy. The arena of play is interesting. 

And I think when people also ask questions, say, aren't video games violent, aren't there a lot of shooting games, what's one of [00:43:00] the most common games that kids like to play in a playground with their imagination, cops and robbers, that it's not exclusive to video games, it's all around us. Do you expect children to to play games that aren't related to what they're seeing on the news, what they're seeing their parents reading about in the newspapers. 

You can't pretend that this is a world that's free from conflict and free from violence and children pick up on far more than we realize. And it's, it is going to be exhibited in play or through art. Well, it's, it's not even, it's not even just that we live in a world of violence is that we're a violent species. 

And we like to, we like to think we're not, this is a psychoanalytic idea. Of course, we like to think. We're non aggressive, but we didn't become the dominant species on the planet by being not aggressive. So when people worry that video games will make people violent, of course, what you first have to understand is people are aggressive and violent. 

They may not be aggressive or violent if the social conditions are [00:44:00] correct, if we live in a civilization, if the temperature is correct, if we have enough food and water, but as soon as those things go out of the window, history will tell us, we go right back to violence. Now, that being said, could it be that video games exacerbate someone's already violent nature? 

I don't know the answer to that. My sense is that it's more that video games, we resonate with them because they allow us to express aggression in a safe way, as you said. But I wonder, perhaps you're aware of any evidence around this subject, the relationship between violence and video games. In terms of the notion that violent video games drive violent behaviors, I'd say the short answer is no, they don't. 

I guess for more detail, there's an excellent book called Moral Combat, Why the War on Violent Video Games is Wrong by Patrick Markey and Christopher Ferguson. And Christopher Ferguson is an accomplished researcher in the area. And it's a book that looks [00:45:00] at this debate and breaks it down and finds that actually a lot of the First of all, the research is conflicting. 

And some of the studies that that claimed to show a link between aggression and video game play actually were not naturalistic at all, creating a video game for the study for the purpose of winding people up and making them annoyed and then testing their aggression. That's, it's not very naturalistic, is it? 

And that they're really, There's a lot of conflicting findings with some studies suggesting actually perhaps there might be a healthy outlet and reduce aggression. And obviously correlation doesn't equal causation, but one of the things that they do point out in this book is countries with numbers of people playing video games and general crime rates. 

Obviously, there's far more going on in the world rather than just people playing video games that will contribute to crime rates. Basically speaking, a lot of the conjecture is based in numbers. Kind of fear and myths. And so it's usually it's violence is a societal issue, isn't it? And we're always [00:46:00] looking to find some sort of scapegoat, some sort of cause when actually it's a complex thing. 

And we know this idea of video game as being introverts who isolate them, isolate themselves is actually untrue. More than 70 percent of people who play video games do play with friends. So it's, it is a stereotype and that there is a lot of fear mongering for For various reasons within the media and politics, that's not to say, and what's interesting is I think whilst the research say over a decade ago focused more on the link between violence and video games, now it's less about violence and more about mental distress and levels of like psychological well being. 

I think there's an appreciation that argument, that debate is over and so it's now shifting and it's said, okay, if they don't, if we can't show that they make people violent, let's look into, does it affect well being? Does it affect mental health of people? I always thought, I think there is a danger of anyone individual perhaps overusing video games as they may overuse alcohol or a [00:47:00] different drug or they may fall prey to gambling as we discussed. 

But I always thought there's a lot of really cool lessons you can learn from video games and take with you to the rest of your life. And that's more my experience. I played video games a lot when I was younger, not so much now. But I wonder, what do you, what did, Alex, what did you play? Sorry, I don't mean to interrupt you, but I'm just really curious. 

I'm a, I'm a Halo guy through and through. Nice. Nice. All right. No, but you were saying, um, what do you think are the biggest lessons someone can take from a video game to real life? So I'm going to use, Get, get personal here. For me, I'm a big fan of the video games developed by a company in Japan called From Software. 

You might recognize, uh, their name. They are the developers behind Dark Souls, uh, Bloodborne, Sekiro, amongst other games. And these games have developed a bit of a reputation for being challenging. I would argue that reputation is a bit exaggerated sometimes, but they're [00:48:00] games that reward you for, uh, approaching carefully, keeping your shield up when you go around the corner, because quite frankly, you don't know what's around the corner and using your head when approaching situations and in these games, it's not unusual to sometimes die to a boss. 

And sometimes have to repeat the fight several times. Sometimes I think I've certainly had bosses where it's been at least 60 tries, which sounds I know sounds ridiculous but actually I've actually over time come to realize in life, there are many situations like that where It does feel like you're failing repeatedly, whether it's applying for jobs, fellowships in the world of research, applying for grants and funding, submitting your paper to a journal. 

Rejection is common. Maybe there are some people out there who are golden and never encounter rejection. I've yet to meet any of them. Me neither. Yeah. And I don't know, but I've, I find In the context of games, it [00:49:00] makes it all the sweeter when one does reach that goal, when that achievement is reached, and you really feel like you've worked for it. 

And it's allowed me to appreciate that every failure can be a lesson, and there is something we can always take forward. And we use the word failure, but really, it's a temporary setback and The true failure is just giving up. It's turning off the console and saying, that's it. I'm not going to play this game anymore and missing out on all the wonderful experiences that potentially it has to offer. 

I think in life, there are many times when it feels safe. It feels like it would be. Uh, reassuring and comfortable to stop trying and not try again, but actually we're doing ourselves a disservice. And sometimes to a certain extent, it is important to be able to sit with discomfort and adversity and push through towards a goal. 

And obviously that can, it depends on the situation. I feel like for me, that's something I've taken away from video games. Yeah, absolutely. And that's [00:50:00] pretty similar to what I, what I've experienced as well. I'd like to talk a little bit about VR because I, I think VR is being explored as a really powerful tool to help people with mental health problems. 

Can you comment on the potential utility of VR to help people with, with mental health difficulties? For sure. So what you have to understand when you're looking at the literature for the use of VR in psychiatry is broadly speaking, there are two main applications. One of which is desensitization, a form of virtual exposure to a stimulus that perhaps, uh, is triggering or difficult. 

And this can be thought of as an example of kind of exposure response prevention therapy, uh, which is a form of therapy that obviously predates VR, but say someone has an arachnophobia. And so as part of the process of desensitization of this gradual increasing level of exposure is first in therapy, you might. 

Say the word spider, you might talk about spiders. No images, just [00:51:00] talking. Then you might show someone like a drawing, like a childish drawing of a spider. Then you might show like an actual more anatomically correct drawing. Then you might work your way up to a photo, then a video. And at some point, perhaps you, like, Going along that framework, at some point you would be in a room with a real spider. 

You might even hold a real spider. But you can see how being in a VR experience with a spider, who can say what size it would be, depends on how your therapist is feeling, could be a nice in between, a nice stepping stone in terms of that exposure. And I think, especially in phobias where there is a potential With most phobias, it's usually a large part is irrational and there isn't a real risk of danger, but something like a driving phobia, you can see how that's a really difficult one to treat because there is a potential risk of danger. 

If something goes wrong, if someone does panic in the process of driving. And I think that's a perfect [00:52:00] example of where VR can be used for exposure in treating in that phobia. So exposure response, prevention, desensitization is one of the most common applications. The other main one is kind of rehabilitation. 

And in truth, this kind of goes hand in hand with what I mentioned about desensitization. But rehabilitation has been actually championed more in the neurology literature, a lot of work around VR based forms of occupational therapy and physiotherapy for individuals recovering from stroke or spinal cord injury. 

And one of the nice things about it is someone could be in a hospital setting, but you can have them in VR. working in the kitchen, working at a cash point, doing things that are similar to their day to day job that they wouldn't be able to do in a hospital setting. So that's nice. And I won't get into all the applications for education that VR has, but there are many. 

And in terms of what's actually been done. So Daniel Freeman. in Oxford, heads the Game Change VR program. And they, whether intentionally or unintentionally, had developed [00:53:00] a reputation for producing VR based interventions for phobias beginning with A. But the first one was Acrophobia, so fear of heights. 

And they did some excellent work where you're in an experience, where you're in a shopping center, where you're like, And you have to go up level by level and complete a task. And what's interesting about the tasks and what I really love is that there's a degree of emotional salience. They're not dry tasks like, Oh, just touch the button. 

Just touch the bubble. Instead, it's something with some relevance. Like a small child has lost her balloon. If you reach out over the balcony on the first floor, you can grab it. Oh, now you're on the second floor. There's a cat stuck in a tree. If you reach out to the cat, you can get it. That's nice. And I think incorporating that in a therapeutic context is important. 

So that's their approach for acrophobia. Yeah. The second phobia, beginning of a is agoraphobia, but specifically agoraphobia for people with psychotic disorders and their VR intervention in that population is an experience where you, you get [00:54:00] on a bus and you have to pay the bus fare. And there are people on the bus and they're talking and there are varying levels of difficulty. 

The bus driver might try to have a conversation with you. The people on the bus might get a bit rowdy. They might even say something about you. And it's. a very nice controlled environment where you can control the level of discomfort and distress and allow people to be exposed to that within a safe environment. 

And actually to date, it's the only nice approved VR intervention for a mental health condition, which was approved earlier this year, um, specifically for severe agoraphobia in psychotic disorders. If it's moderate or mild, it recommends It basically is approved for severe with moderate or mild, it's possible, but they emphasize that this is an area of growing research and more evidence is needed. 

But that's where we are in terms of the latest and the cutting edge for VR interventions for mental health. And that's really interesting because going back to what we were talking about about predictive processing, what that reveals is that [00:55:00] in all those situations, really, the patient is perceiving fear. 

So around heights, they're perceiving fear, or out, or around crowds, whatever the stimulus is, and what you're, learning through the VR program is to readjust your expectations that actually it's not a particularly dangerous situation. And it's so interesting that even an artificial situation, whether it's something really simple, like an actual drawing or a VR experience, your mind can somehow take that as a solid anchor, a solid cue that the stimulus in question is not in fact dangerous, and then somehow transfer it to real life. 

It's fascinating. Absolutely. We perceive and we process so much unconsciously that we don't realize. Have you ever heard of the uncanny valley effect? Yes, yeah, maybe you can tell tell us a bit. It's the idea that when you're say recreating a [00:56:00] Human face say whether it's for a film or a cartoon the closer and closer you get to It being looking like a real person's face, but not being quite there yet is quite unsettling and it's, and it's unclear why that would be the case, but there's something about things that are close to human, but not quite human, making us uncomfortable and it can be very subtle, but as obviously video game graphics improve and as CGI improves, I think it's something we're encountering more, and there is a paper that looks at the uncanny valley effect in VR and actually how VR participants sometimes prefer. 

Yeah. Having a, um, a model of, of, of the player character of themselves, which is more of a robot or more of a silhouette based model, rather than trying to look like a real person. Because it's not quite there yet, and it's unsettling. And there are evolutionary theories about why that might be the case. 

Why have we evolved to find things that are close to us, but not quite us frightening. And some people suggest, oh, it's when we competed with other. other species like Neanderthals and whatnot that probably were quite similar to us. That's all, that's [00:57:00] conjecture, but it's just one of many examples of ways in which we process things unconsciously that can affect our emotional and mental states. 

And we don't know why. Yeah. And even at the stage VR is at now, whatever the flaws, it's clearly really powerful. And as we've said, can help people with mental health problems, but again, exploring the other side of the coin. Do you worry that as VR improves, let's say in the next 10 years? VR gets stunningly lifelike and can replace real life experiences in many ways. 

And I'm thinking about things like AI girlfriends and boyfriends or a kind of AI job that, you know, can give you more fulfillment. Perhaps then even your real life job. Do you worry that many people can kind of escape into a VR world and spend most of their time in that virtual reality? Is that a concern you have? 

I think, I wouldn't necessarily have that [00:58:00] concern for VR specifically. And one of the biggest barriers to greater adoption for VR is the convenience factor. And that may change as the technology improves, but as it stands, there's a reason why many people will come home and switch on the TV. It's seamless. 

It's easy. It requires a minimal discomfort with VR as great as it is. And I'm a big fan of VR. I have a valve index headset myself, which I use. It doesn't get around the fact that you have to strap it onto your head after some time. Like I can play games, video games on a television for hours, but with VR, my sessions probably wouldn't be longer than a couple of hours. 

It takes it out of you more. And I think that there's a big barrier to adoption. And I think. Truthfully speaking, I think people outside of the sphere of video games and VR really over egg the difference between a VR experience and a gaming experience, but I think on a flat screen, when you're immersed enough, when you're engaged, it might as well be VR. 

You're in. It's like a [00:59:00] good film. You're in just like a movie. Exactly. To some extent you dissociate and you were just experiencing the media experience in front of you. You don't need VR for that necessarily. So I don't think those fears are necessarily exclusive to VR. And I think those things are Those things are already happening right now. 

And ultimately people can be allowed to make bad decisions. Yeah. I don't want to be that psychiatrist that says, maybe don't talk to your video game waifu 24 seven touch grass, but yeah, we should say that people can make bad decisions. To be honest, it is an interesting question in terms of, and I think it's more looking at what are people getting out of it. 

So is it for social connection? Is it for a sense of social connection? And maybe that will change as language learning models become better and better. Maybe because I think there's an uncanny valley effect with language learning models as well. Like you can have a conversation, it can feel like it's flowing. 

And then suddenly there's a hallucination or as I prefer to call them [01:00:00] confabulations. I think these models are still quite prone to that. And it completely takes you out. And. Really interesting, relevant. I promise there was a company in the U S I'll have to look up the name where they provide talking therapy, usually CBT based models for an app, but without telling any of the users, they temporarily, I think maybe for a few hours or for a day, switched it to an AI, a language learning model. 

And with this app, they always ask how satisfied you are after. And satisfaction didn't go down. It was the same, if anything, a bit better. As soon as people were told that it was an AI, and I have to remind you, nobody consented to this. The ethics is ridiculous. It's a company's private study. As soon as they realized they were informed afterwards, actually you were talking to an AI, the satisfaction dropped massively, like there's a real. 

That's predictive processing. Absolutely. And to extrapolate, I guess a fear of mine is what will happen is not necessarily [01:01:00] a fear. We do need to incorporate AI more in our workflows to make things more efficient and to allow us fundamentally to spend more time with patients. I would argue it can help us to spend more time with patients rather than fobbing off patients on AI. 

a fear would be in a, uh, let's say worst case scenario, we have a two tiered system where those who can't afford care are fobbed off on AI based approaches and those who can pay to see a person directly. And we're almost out of time, but maybe you could tell me a bit about the work you guys do at Gaming the Mind and where people can find out more. 

Yes, so check us out on GamingTheMind. org Or on BlueSky or Twitter, at GamingTheMind. We are a charity composed of mental health professionals focused on, uh, mental health within the video games community and video games industry. Uh, looking to break down uh, challenge stigma and raise awareness. We do a bunch of things. 

We do some teaching sessions with games development students at the National Film and Television School. We also run a reset room, a low sensory stimulus space at London Comicon and other major public events [01:02:00] where people who are feeling a bit overwhelmed can come and relax, engage in mindfulness exercises, talk to someone if they need to, or just chill out with our sound cancelling headphones and colouring in our origami. 

We also do consulting for people developing video games, and we do a lot of work with indie developers. One such project was with the developers of a game called Before I Forget. which depicts the experience of a woman sadly going through the stages of dementia. And we advise on kind of the depiction of dementia in that game to try and make it more accurate and sensitive. 

And that game was nominated for a BAFTA. Didn't win, but maybe one day we'll get there. In addition, we do some, we've done some consulting work contributing to a government white paper on loot boxes. And I'm conscious we're at the end of, near the end of time. So I won't get into what loot boxes are, but I feel like there's a lot discussion to be had there at some point, but yes. 

An exciting thing that's coming up is in 2025, we will be launching a fund for indie independent game developers, indie developers who are looking to develop [01:03:00] games based around mental health themes and mental illness. And part of why we're doing this is we've worked with a lot of developers and many of them do ask, Oh, I've got this great idea, but just a little bit of support. 

So we are going to be launching this fund. So keep your eyes peeled on our social media and our website for that. It will be launching at some point in the next year. Wonderful. Hamilton, thank you so much for joining me. Thank you, Alex. It's been a pleasure.