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The emotional and therapeutic impact of video games for health: Is motivation to improve more important than expectations for improvement?

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The emotional and therapeutic impact of video games for health: Is motivation to improve more important than expectations for improvement?

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Content Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 1

The Emotional and Therapeutic Impact of Video Games for Health: Is Motivation to Improve
More Important Than Expectations for Improvement?

Jeffery A. Newell
University of Southern California

Committee:

Chair: Steven R. López, Ph.D., Professor of Psychology and Social Work, University of
Southern California

Carol Prescott, Ph.D., Professor of Psychology and Gerontology, University of Southern
California

Stephen Read, Ph.D., Professor of Psychology, University of Southern California

Marientina Gotsis, M.F.A, Research Assistant Professor, Interactive Media & Games Division,
School of Cinematic Arts, University of Southern California

December, 2015
Master of Art (PSYCHOLOGY)

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 2
Table of Contents
Abstract……………………………………….…….…....…………....…………....…….…..…...3
Introduction………………………………….…….…....…………....…………....……….……...5
Methods……………………………………….…….…....…………....…………....……….…...11
Results……………………………………………………………………………………………21
Discussion…………………………………………………………………………….……….....30
References………………………………………………………………………………………..34
Tables………………………………………………………………………………………….....40
Figures…………………………………………………………………………………………....49
Appendix…………………………………………………………………………………………63
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 3
Abstract
Self Determination Theory (SDT) has been used to explain the benefits observed from video
game play. However, this theory may over-rely on the role of motivation and self-determination
in behavior change. The present study investigated how expectations may influence behavior
change from video game play and hypothesized that changes in outcomes from pre- to post-play
would not be accounted for only by motivation and self-determination as SDT claims. To
accomplish this, 47 participants were recruited to play two video games for mental health. In
order to isolate the impact of expectations, participants were randomized to a “high expectation”
or “low expectation” condition in which the “high expectation” group was told about the
scientific evidence supporting the benefit of these specific games, and the “low expectation”
group was told there is no evidence to suggest these games work. Expectations about how
helpful the game will be and their motivation to play were assessed before and after each game,
as well as changes in emotions and therapeutic skills the game was meant to teach. Changes in
expectations and motivation were then correlated with changes in outcome measures, after which
a mediation model was used to assess whether expectations or motivations were more
responsible for observed changes. Flow was also measured after video game play to measure in-
game enjoyment. Results found that expectations, flow, and motivation were all significantly
associated with the changes in emotions and therapeutic skills that each game was targeting. A
mediation analysis revealed that expectations mediated the impact of motivations on outcomes,
and flow meditated some, but not all of the impact of expectations on outcomes. Taken together,
the results of the study add to a growing body of literature demonstrating video games’ potential
aid in improving mental health, especially over a short period of time. Further, these results
suggest that SDT may be over-estimating the role of motivation and self-determination as agents
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 4
responsible for changes in one’s growth and development. Specifically, this study found that
expectations akin to the placebo effect may in fact be responsible for some of the changes
currently being attributed to SDT. Future studies are encouraged to investigate the full extent of
the relationships between expectations, flow, and motivation.
Key Words: Self-Determination Theory, Expectations, Games for Health, Low-intensity
interventions, mediation.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 5
The Emotional and Therapeutic Impact of Video Games for Health: Is Motivation to Improve
More Important Than Expectations for Improvement?

Introduction
In 2012 the United States (U.S.) Substance Abuse and Mental Health Service
Administration (SAMHSA) predicted that as many as 43.7 million adults living in the U.S.
suffered from a mental illness that year (SAMHSA Report, 2012). The SAMHSA report states
that this figure represents 18.6% of adults in the U.S.; in other words, nearly one in five adults
living in the U.S. in 2012 actively experienced at least one episode of a mental illness. Globally
the burden of mental illness far outweighs our current ability to provide services to all who need
them and most individuals with a mental illness will receive no professional aid or intervention
(e.g., Hu, 2003; Wang, Lane, Olfson, Pincus, Wells, & Kessler, 2005). This large discrepancy
between those who need mental health care and those who actually receive care has many
contributing factors. Alan Kazdin (2011) identified many barriers to receiving mental health
treatment including lack of insurance, inadequate access to facilities and practitioners (i.e.
individuals living in rural or other under-served areas), stigma associated with mental illness,
concrete obstacles of daily living including work schedules and transportation issues, and finally
ethnic and cultural issues. An additional factor contributing to this dearth of mental health
treatment provision is that mental health care is overwhelmingly conceptualized as a one-on-one,
client-and-therapist interaction in a psychotherapeutic setting (e.g., Kazdin, 2011). Given the
sheer volume of adults suffering from some form of mental illness both domestically and abroad,
any treatment-delivery system predicated on a one-on-one interaction will inevitably leave many
people without access to care. Thus, according to Kazdin and Blase (2011), one way to address
many existing barriers simultaneously is to expand how we conceptualize mental health
treatment beyond a one-on-one modality. Kazdin and Blase (2011) view new forms of
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 6
technology such as internet-based treatment programs and mobile phone applications as ideal
tools to help move beyond the existing one-on-one mental health treatment model. Video games
are one such form of technology that has demonstrated an ability to improve mental health
outcomes (among others).
Video Games and Mental Health Care
The idea of using video games to specifically target and promote personal growth and
development aka “serious games”, has begun to receive increased attention (e.g., Michael &
Chen, 2005). Arriaga, Fernandes, and Esteves (2013) have defined serious video games as,
“designed mostly for (although not limited to) training and educational purposes in order to
positively impact peoples’ health and social outcomes” (pp. 56). Serious games have led to
successful outcomes in a diverse range of fields including medical treatment adherence (e.g.,
Beale, Kato, Marin-Bowling, Guthrie, & Cole, 2007; Kato, Cole, Bradlyn, & Pollock, 2008),
general health and physical education (e.g., Baranowski, Bunday, Thompson, & Baranowski,
2008; Papastergiou, 2009), as well as cognition (e.g., Feng, Spence, & Pratt, 2007; Basak, Boot,
Voss, & Kramer, 2008), and social functioning (e.g., Granic, Lobel, & Engels, 2014). Although
much less empirical investigations exist supporting video games’ ability to improve mental
health when compared to other areas like improvement of visuo-spatial skills, early research in
this area shows promise. For instance, there is direct empirical evidence linking video game play
to an increase in positive emotions, improved mood, decreased stress (e.g., Ryan, Rigby, &
Przybylski, 2006; Russoniello, O’Brien, & Parks, 2009a, 2009b), and enhanced general well
being (e.g., Johnson, Wyeth, & Sweetser, 2013). Russoniello, Fish, and O’Brien (2013) were
able to significantly reduce depressive symptoms in depressed participants by putting them on a
month-long video-game-play regimen, while Christensen, Miller, Appleby, Corsbie-Massay,
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 7
Godoy, Marsella, and Read (2013) were able to significantly reduce the amount of sexual shame
men who have sex with men felt after playing a virtual game (called SOLVE). Finally,
Wilkinson, Ang, and Goh (2008) reviewed the use of online games for mental health therapy and
found that online video games have helped the recovery of conditions such as aggression,
anxiety, attention deficit hyperactivity disorder, autism, psychotic disorders, and personality
disorders. Although the evidence of how beneficial video games can be for those who play is
mounting (e.g., Granic, Lobel, & Engels, 2014), this is still a relatively new field of study
needing more attention (Michael & Chen, 2005). Consequently, much research thus far has
prioritized outcomes establishing if games work in lieu of why games work. This has left a
paucity of evidence elucidating that factors that cause one to benefit from video game play.
Why Video Games Help: A Self-Deterministic Perspective
Self Determination Theory (SDT; Deci & Ryan, 1985; 2010) is a model explaining
psychological growth and development that has been used to explain how video game play
changes behavior (e.g., Baranonwski et. al., 2008; Wilkinson, Ang, Gho, 2008; Przybylski,
Rigby, & Ryan, 2010; Przybylski, Rigby, & Ryan, 2010; Connolly, Boyle, MacArthur, Hainey,
& Boyle, 2012). SDT posits that autonomy, competence, and relatedness are all needed to
enhance one’s motivation to pursue a goal or complete an activity. Enhanced motivation is
thought to be the mechanism thorough which personal growth and development occurs. As the
name of the theory implies, one feeling a sense of ownership and autonomy over their thoughts
and actions is the key component encompassing all change. SDT asserts the level of motivation
one has to complete an activity will mirror the extent to which they believe they have
autonomously chosen to complete the activity. In other words, self-determination will lead to
more motivation, and more motivation will result in more growth and change. SDT defines the
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 8
ultimate form of autonomous action, intrinsic motivation, as an activity that is pursued for no
other reason than the enjoyment of the activity, and the person’s decision to participate is
completely autonomous (Deci & Ryan, 1985). Since video games are traditionally a leisure
activity, SDT is thought to be connected to the benefits of video game play because most people
are playing them for intrinsically motivated reasons.
One major shortcoming with the SDT theory is that it requires the presence of autonomy,
competence, and relatedness for change to occur. However, a robust body of literature
concerning the placebo effect has demonstrated that nothing more than one’s expectation for
change can cause change (e.g. Finnis, Kaptchuk, Miller, & Benedetti, 2010). Better known as
expectancy, it contradicts SDT ‘s explanation for growth, development, and change because it
can occur independent one’s sense of autonomy or motivations (e.g., Finnis et al., 2010).
Consequently, since the SDT model does not account for gains seen outside of those explained
by one’s motivation and sense of autonomy, expectations represent a factor that may account for
positive gains currently being attributed to SDT. The general aim of the present study is to
evaluate how both motivation and expectancy are associated with short-term changes in
outcomes related to video game play. This will hopefully shed more light on the relationship
between expectancy, motivation, and changes in outcomes after playing a video game for mental
health.
Present Study
To illuminate the associations between expectancy, motivation, and changes in outcomes,
two serious video games for mental health were tested for their emotional impact and ability to
teach therapeutic skills over a short-term period. Questions relating to motivation, expectancy,
credibility, emotions, anxiety levels, and therapeutic skills were collected before and after each
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 9
video game was played. Video games were played on separate days no more than seven days
apart. Participants were required to attend both study sessions, thereby eliminating much
between-subject variation when discussing how these factors changed in relation to two separate
video games. The design of this study has the following specific aims:
Aim 1: Emotional Impact and Therapeutic Skills
The first aim of this study is to investigate how each video game changed the self-
reported emotions and knowledge of therapeutic skills for every participant. Emotions have been
chosen as one outcome because emotions are shorter in duration than moods (Oatley, Keltner, &
Jenkins, 2006) and are typically focused on a specific object, whereas moods are free-floating
and objectless (Frijda, 1993). Therefore, changes in emotions from pre- to post-play can
reasonably be attributed to the experience of playing the video games. Therapeutic skills have
been chosen as an outcome because they represent the therapeutic principles each video game
aims to improve. An analysis of these outcomes is necessary because neither game has been
formally evaluated, therefore, it must first be established that these games evoke some form of
change in participants before an analysis of factors causing such changes can be completed. A
paired t-test was used to evaluate changes in emotions and therapeutic skills before and after
video game play. One game, Blowing Blues, was expected to have the emotional impact of an
increase in positive emotions, attention, and serenity, but a decrease in negative emotions and
distress/anxiety. Blowing Blues was also expected to concurrently improve the therapeutic skill
of mindfulness for those who play. The other game, Nevermind, was expected to increase the
emotions of fear, negative emotions, and distress/anxiety. Nevermind was also expected to
concurrently improve the therapeutic skill of Emotion Regulation for those who play. A
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 10
description of each video game and the rationale for such expected changes in emotions and
therapeutic skills will take place in the Methods section.
Aim 2a: “High” and “Low” Expectation Group Differences (Experimental Manipulation)
All participants were randomly assigned to a “high expectation” or “low expectation”
condition where each condition was communicated a different message about how much
evidence we have to support the benefit of playing each game. This was done in an effort to
highlight the effect of higher and lower levels of expectancy on outcomes. It is expected that
when we enhance the expectancy about the benefit of each game there will be greater subsequent
changes in outcomes. A mixed effects linear regression model was used to test for condition
effects of the game via a time by condition interaction.
Aim 2b: Associations of Expectancy and Motivation with Changes in Emotional Impact
and Therapeutic Skills
Since the study measured expectancy and motivation at pre- and post-game play, we were
able to test how these were associated with changes in outcomes independent of the experimental
manipulation. In order to understand these associations, a two-fold approach was taken. First,
Pearson correlations with expectancy and motivation were examined in relation to the outcomes
pre- and post-play in order to determine if expectancy and motivations are related to concurrent
levels of emotional impact and therapeutic skills. Second, a mixed effects linear regression
model was used to examine if the change in expectancy or motivation was associated with the
change in these outcomes.
Aim 3 In-game Experience.
Flow has been cited as a potential mechanism causing behavioral and emotional changes
during video game play. This is because when people play video games they enjoy the
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 11
experience, which creates flow and reinforces their desire to continue playing in the future
(Boyle, Connolly, & Hainey, 2011; Hsu, & Lu, 2004; Sherry, 2004). Jon Sherry (2004) has used
the concept of flow to understand user engagement in video games by comparing the principles
that facilitate flow to the principles found in most video games. This comparison showed that
video game play typically achieves every component thought to be essential for achieving a flow
state. Therefore, we analyzed flow as a measure of how the user’s experience of playing the
game itself may have influenced outcomes. This is important because when addressing
phenomena in which many potential factors are all related to changes in outcomes it is best to
evaluate them together instead of in isolation (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001).
A mixed-effects linear regression was therefore used to test for associations of flow with changes
in emotions and therapeutic skills.
Aim 4: Mediation of Changes in Emotional Impact and Therapeutic Skills
Finally, a linear regression change score model was only explored when changes in the
outcomes were related to changes in expectancy and flow or motivation separately. These models
were used to determine if any predictor is independently associated with changes in the outcome.
Methods
Overview
The study consisted of two study sessions that were spaced anywhere from 1 to 7 days
apart. At each study session participants answered questionnaires, played a video game, and then
answered more questionnaires. Participants were not required to attend both study sessions in
order to be included in the statistical analysis. The full procedure will be described in the
“procedure” section below.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 12
Design
The aims of this paper were evaluated using a randomized, mixed-method crossover
study design measuring outcomes both within and between groups. Participants were randomized
in a 1:1 ratio to the “high expectation” or “low expectation’ condition. Randomization also
included a random assignment for the order in which participants played the two video games.
This crossover design controlled for possible order or sequencing effects resulting from playing
one game before the other. A main effect was tested for the “high expectation” and “low
expectation” groups. The primary outcome measure was changes in self-reported emotions,
distress/anxiety, emotion dysregulation and mindfulness.
Measures
Emotions - The participant’s emotional experience was assessed at baseline before any
video game play and immediately following the completion of each game using the Positive and
Negative Affective Schedule – Expanded Form (PANAS-X) (Watson & Clark, 1999; Watson,
Clark, & Tellegen, 1988). The PANAS-X is a self-report measure that contains 60 words
representing core emotional categories (See the Appendix for an example of the PANAS-X).
Items include categories covering general dimensions of positive emotions (active, alert,
attentive, determined, enthusiastic, excited, inspired, interested, proud, strong) and negative
emotions (afraid, scared, nervous, jittery, irritable, hostile, guilty, ashamed, upset, distressed).
The present study also included the PANAS-X basic positive emotion scales of self-assurance
(proud, strong, confident, bold, daring, fearless) and attentiveness (alert, attentive, concentrating,
determined). The present study also included the PANAS-X basic negative emotion scale of fear
(afraid scared, frightened, nervous, jittery, shaky) and an “other” affective state of serenity (calm,
relaxed, at ease). The scale prompts the user to think about each emotion and rate their
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 13
experience of that emotion. The scale has been validated to assess eight distinct temporal
categories, and for the purposes of this study participants will be asked how they feel about each
emotion, “Right now (that is, at the present moment)”. The PANAS-X was converted to a 1-100
Visual Analog Scale (VAS) with labels ranging from 0 (Very slightly or not at all) to 100
(Extremely). Items were presented in random order with no sub categorizations indicated. The
present moment temporal cue was tested with a sample of 660 participants and showed high
levels of validity and reliability (Watson Clark, & Tellegen, 1988).
Distress/Anxiety – Participants were given The Visual Analog Scale-Anxiety (VAS-
Anxiety) at pre- and post-game play in order to capture changes in levels of distress and anxiety.
The VAS-Anxiety scale is a 4-item slider scale that presents the following four pairs of diametric
word anchors: “Completely Relaxed” to “Totally Stressed Out”, “No Muscle Tension At All” to
“Most Muscle Tension Ever”, “No Fear At All” to “Most Fearful Ever”, and “Completely At
Ease” to “Completely On Edge”. These word anchors contain no numeric reference points. The
VAS-Anxiety was created to provide a valid measure of self-reported anxiety and has shown
good internal consistency with the four items having a Cronbach’s alpha of .90 (Jordan-Marsh,
Gotsis, Baron, Kaplan, Lee, & Hashemian, 2013) (See Appendix for an example of the VAS-
Anxiety Scale).
Emotion Dysregulation – To capture the therapeutic skills targeted by Nevermind,
emotion regulation, the Difficulties in Emotion Regulation Scale (DERS) was given at pre- and
post-game play. The DERS (Gratz & Roemer, 2004) is a 36-item scale meant to capture one’s
emotion regulation abilities in response to negative emotional arousal. It also measures one’s
ability to act in a desired way regardless of the emotional arousal context. Items were converted
to a 0 (Almost Never) to 100 (Almost Always) VAS scale but maintained the originally-validated
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 14
descriptors. The DERS has six reliable and validated factors that capture different aspects of
emotion dysregulation (Gratz & Roemer, 2004). DERS nonacceptance is a tendency to have bad
reactions to or be unaccepting of negative emotions, DERS goals reflects difficulties completing
tasks or accomplishing goals when confronted with a negative emotion, DERS impulse assesses
how out-of-control the person feels when experiencing a negative emotion, DERS awareness
measures how aware one is of their emotional states, DERS strategies reflects how many
strategies or techniques one has to address negative emotions, and DERS clarity reflects the
extent to which one has a clear understanding of their emotions. Increases in DERS are meant to
reflect greater dysregulation. The original DERS prompts participants to rate each item for how
it typically applies to them; but for the purposes of the present study the instructions have been
modified to ask participants how the items relate to them at the present moment (see Appendix
for the modified DERS). The DERS has demonstrated high internal consistency, good construct
and predictive validity, as well as good test-retest reliability (Gratz & Roemer, 2004).
Mindfulness - To capture the skills targeted by Blowing Blues, mindfulness and
relaxation, the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R) was administered
before and after each game was played. CAMS-R is an ideal scale for measuring the meditation
skills taught in Blowing Blues because it conceptualized mindfulness in a broad, multifaceted
way that is meant to capture a variety of meditation trainings from a wide array of subjects
through the 12 items it asks (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007).
Participants were told that people have a variety of ways of relating to their thought and feelings,
and asks them to rate each item as it applies to them. Items were converted to a 0 (Not At All) to
100 (Almost Always) VAS scale but maintained the originally-validated descriptors. The CAMS-
R has shown good levels of convergent and discriminate validity, with an adequate degree of
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 15
internal consistency (Feldman et al., 2007). The CAMS-R concurrently measures attention (i.e.
how actively the person is trying to pay attention to their bodily cues) present focus (i.e.
prioritizing a mindset predicated on paying attention to the present moment) awareness of
emotions, and acceptance of emotions (See Appendix E for an example of the CAMS-R). These
four domains can be combined to indicate a total score for mindfulness.
Expectations - Participant’s expectation for how much the video game will teach them
the intended therapeutic skills was assessed at pre- and post-game play using the
Credibility/Expectancy Questionnaire (CEQ). The CEQ was developed for clinical settings to
measure how much a patient believes a given psychotherapy will benefit them (Devilly &
Borkovec, 2000). These beliefs are captured by two factors, a cognitive-based belief in the
credibility of the treatment (i.e. credibility) as well as an affective expectation of improvement
(i.e. expectancy). Expectancy has shown particular strength in predicting positive outcomes. The
CEQ tells subjects that beliefs often have two aspects, what one thinks will happen (i.e.,
“credibility”) and what one feels will happen (i.e., “expectancy”). Subjects are then presented
with two sets of questions in which they are asked to answer the first set of questions based on
what they think, and the second set of questions based on what they feel (See Appendix for an
example of the CEQ). Items were converted to a 0 (Not at all useful) to 100 (Very useful) VAS
scale but maintained the originally-validated word anchors. Wording on the CEQ was modified
to be applicable to the games being played in the study. Specifically, the pre-game assessment
asked how much they expect the game to help them after they had been given all the information
about the game. The post-game assessment asked them to report how much they believe the
game actually helped them. Therefore, any changes in CEQ scores will reflect the difference
between how much they expected the game to work and how much they felt the game actually
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 16
did work. Each factor of the CEQ has demonstrated high internal consistency, good test-retest
reliability, and stability in a variety of populations (Devilly & Borkovec, 2000).
Motivation - The motivation each participant feels to learn to target skills of each game
was measured at pre- and post-game play with the Revised Personal Involvement Inventory
(RPII). The RPII is a 10-item semantic differential scale that lists opposing adjectives that are
connotative to the content prompt (Zaichkowsky, 1994). For the present study the content
prompt was “To me, improving my meditation and relaxation skills is:” for Blowing Blues and
“To me, improving emotion regulation skills is:” for Nevermind (see Image 1 for example).
Participants decide the degree to which they agree with one of the two opposing adjectives,
having 7 radial dials to chose from. Picking the middle is given a score of 0, and agreeing with
an item to the highest degree is a 3 for words with a positive connotation in relation to the
content prompt, and -3 for words with a negative connotation in relation to the content prompt.
The 10 word-pair scores (i.e., of -3 to 3 for each of the 10 items) are given a single mean score,
and this mean score is meant to reflect how much the person values the topic within the content
prompt. The RPII was chosen as a measure of motivation in this study because it directly and
validly assesses how much personal value one places in the presented topic. Within SDT, the
amount of motivation one feels to perform an activity or achieve a goal is thought to reflect how
much personal value they place in the activity or goal (Deci & Ryan, 2002). According to SDT,
an increase in the personal value one ascribes to an activity or goal will be the best predictor later
growth or development. Thus, the present study will consider an increase in RPII scores to be
analogous to an increase in the SDT conceptualization of motivation. RPII will be referred to as
motivation for the remainder of the paper.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 17

Flow –An adapted version of the Flow State Scale (FSS) was used to evaluate the extent to

which participants were engaged with the game while playing (Jackson & Marsh, 1996). As
mentioned, immersion or losing one’s sense of self is a central component to flow
(Csikszentmihalyi, 1975, 1990), making the FSS a fitting measure for this construct. FSS
respondents are asked to think back to a time when the activity of interest resulted in what they
consider the optimal experience of that activity (See Appendix for an example of the FSS). The
scale tries to capture the level of flow from these individual experiences by assessing nine
dimensions from a factor scale. Each dimension is comprised of four items (36 total items) that
were converted to a 1 (Strongly disagree) to 5 (Strongly agree) VAS Scale with all originally-
validated word and number anchors maintained. Although all nine dimensions were assessed,
Image
1

RPII
Scale
as
participants
saw
it
for
Blowing
Blues,
called
Motivation
in
this
study

Notes:
Number
anchors
are
not
given
with
this
scale.
For
instructions
on
how
to
calculate

scores,
see
(Zaichkowsky, 1994). This scale as asked at pre- and post-game play.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 18
only FSS autotelic was included in the analysis because it is the best single measure of one’s
flow experience during an activity and it is also thought to reflect the feeling of intrinsic
motivation having taken place (Jackson & Marsh, 1996). The items that comprise FSS autotelic
include: “I really enjoyed the experience”, “I loved the feeling of that performance and want to
capture it again”, “The experience left me feeling great”, and “I found the experience extremely
rewarding”. The FSS’ nine scales’ validity was supported through confirmatory factor analysis,
while overall the scale demonstrated good internal consistency (Jackson & Marsh, 1996). Going
forward FSS autotelic will be referred to as flow.
Demographic Variables. Participants additionally reported their age, sex, family
income, race and ethnicity.
Participants
A total of 49 participants enrolled in the study, with 47 of 49 completing both study
sessions. Inclusion criteria was that a) participants were required to be between the ages of 18
and 65, b) they must have indicated that they play interactive video games, and c) that they are
not severely anxious or depressed as assessed by the Patient Health Questionnaire-9 and the
Generalized Anxiety Disorders-7. Demographic results indicate that 59.09% of participants were
male, were overwhelmingly single (95.45%), most of them had some exposure to a college
education (72.73%), and many came from high-income families (68.18% have a family income
greater than $75,000 per year). See Appendix for full demographics and PHQ-9 and GAD-7
information.
Procedure
Participants came in for two separate study sessions in which one game was played at
each session. Both study sessions were supposed to take place within 1-7 days of each other.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 19
Upon arrival, participants were placed at a desk with nothing other than a computer or laptop on
it. All items that had the potential to distract participants were removed from the room prior to
any study session, and during video game play the lights in the room were turned off and all
players wore noise-cancelling headphones to maximize immersion. Research assistants remained
in the room during video-game play to answer any questions participants might have while
playing the game. Upon arrival, participants first filled out the PANAS-X, DERS, and CAMS-R.
They were then given information about the video game they were about to play including how
to play the game, why the game was made, how the game is meant to help them, and what
therapeutic skills they might learn from playing the game. After learning about the games
participants then filled out the expectation, motivation, and VAS-Anxiety measures. Participants
then played the video game. After playing the video game participants filled out the PANAS-X,
DERS, CAMS-R, VAS-Anxiety, expectation, motivation, and flow measures. This concluded the
study session. The second study session was run the same as the first study session except the
participant would play whatever game they did not play in the first study session. Each study
session typically took 35-60 minutes to complete.
Manipulation of Expectations. The “high expectation” and “low expectation”
manipulated occurred in several ways. All participants were given the same message about how
to play the game, why the game was made, how the game is meant to help them, and what
therapeutic skills they might learn from playing the game. However, after this was explained
those randomized to the “low expectation” condition were told:
To date, studies have been inconclusive about how well video games can work to
help someone improve their emotions. Nevermind [or Blowing Blues] specifically
has never been formally tested, so there is no evidence to suggest that this game
will actually help you learn how to regulate your emotions [or mindfulness skills].
Since this game is still new, we’re really interested in how the mechanics of the
game work and how the user interface performs”
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 20

Alternatively, those in the “high expectation” condition were told:

Nevermind [or Blowing Blues] has won multiple awards in the video game
industry including first place prize at the ‘Games for change’ festival in 2014. In
addition to industry accolades, therapists all over the country are currently using
the game to treat a variety of mental illnesses. Therapists using this game as part
of a psychological intervention have reported that it is highly successful in
helping people master their own stress and anxiety [or mindfulness skills]. Studies
on Nevermind [or Blowing Blues] have demonstrated that this game is highly
effective at increasing emotion regulation [or mindfulness]. Most people who play
this game report that they would highly recommend this game to a friend who
struggles with their ability to regulate their emotions [or relax/meditate].

To further legitimize these statements all study sessions for the “low expectation” group were
completed at the USC School of Cinematic Arts where each video game was created, and
participants in the “high expectation” condition completed both study sessions where the
psychology department is located. A final way in which the manipulation was reinforced was
that I communicated that I was a therapist in training with the “high expectation” participants,
whereas with the “low expectation” participants I never mentioned what area of study I am in.
Video Game #1: Blowing Blues. Blowing Blues is a single-player game designed to help
one relax and meditate by having the player focus on, and “blow away”, personal life stressors.
The game was designed based on several core principles of mindfulness, and is played on any
laptop or desktop computer. It works by turning a laptop’s microphone into a wind-sensor that
can register how hard or soft a player is blowing into the microphone. Players are asked to enter
stressors from their lives they would like to meditate about. Once the stressors have been entered
the game brings the player into the level in which active meditation occurs. A full description of
Blowing Blues can be found in the appendix.
Video Game #2: Nevermind. Nevermind is a single player, horror-themed video game in
which the user works to collect clues in order to solve a mystery within the game. Nevermind
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 21
was made with the central premise of creating a sense of self-control and self-efficacy for the
user. This is accomplished by giving the user real-time biofeedback, and teaching them that
when they are fearful, frustrated, or angry, and if their heart rate increases (which prevents them
from advancing further into the game) they are the ones who will ultimately be able to calm
themselves down. The dark and often morbid imagery within the game is meant to illicit fear,
while the challenging puzzles are meant to evoke anger and/or frustration; all of which are
excitatory emotions that increase one’s heart rate (Ekman, Levenson, & Friesen, 1983; Jost,
1941; Levenson, 1992). Consequently, one is given ample practice slowing down their heart rate
throughout the game. Evidence in support of Nevermind’s potential efficacy comes from Stress
Inoculation Training (SIT) literature. The central premise of SIT rests in its inoculation
component, which calls for one to be exposed to a stimulus strong enough to elicit defensive
mechanisms, yet not so strong as to overwhelm the individual (Barlow, 2007a; Meichenbaum,
1975a, 1975b, 1993). Inoculation is a key component in therapy for several psychological
disorders including Panic Disorder, Agoraphobia, and Social Anxiety Disorder (Barlow, 2007b).
In SIT, allowing individuals an opportunity to experience and successfully deal with minor
stressors increases resilience and bolsters psychological preparedness and coping mechanisms
(Barlow, 2007a). A full description of Nevermind can be found in the appendix.
Results
Ordering Effects.
A mixed effects linear regression model was used to test for ordering effects of the game
via a time by order interaction. For the regression model “order” refers to whether each
participant played Blowing Blues or Nevermind first. Generally, there were no group differences
based on the order in which participants played the video games. However, CAMS-R attention
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 22
had a significant interaction for Nevermind (p <.05), while there were no significant interactions
for Blowing Blues. The interaction was such that individuals who played Nevermind first showed
a decrease in CAMS-R attention scores, while those who played Blowing Blues first showed an
increase in CAMS-R attention. However, since these values did not differ significantly at the
post-assessment, and, since this was the only significant interaction among all primary measures
this interaction is likely the result of type-I error and that the order in which the games were
played had no impact on the overall results.
Aim 1: Emotional Impact and Therapeutic Outcomes
Statistical Analysis: A paired t-test was used to test for changes in self-reported
emotions and therapeutic skills (Table 1).
Blowing Blues (Emotional Impact). There was a significant reduction with small effect
sizes in both PANAS-X fear and PANAS-X negative emotions (p <.05, d = -.38 and -.36
respectively), while there was a significant increase with a medium effect size for PANAS-X
serenity (p <.001, d = .54). There was also a significant reduction in VAS-Anxiety with a large
effect size (p <.0001, d = -.85). Blowing Blues (Therapeutic Skills). There was a significant
reduction in DERS goals (p <.05) and DERS impulsiveness (p <.0001), with both changes
having a medium effect size (d = -.38, and d = -.43 respectively). There were no significant
changes in CAMS-R or any of the other DERS domains.
Nevermind (Emotional Impact). There was a significant decrease with a large effect
size for PANAS-X serenity (p <.0001, d = -1.16), while there was a significant increase in both
PANAS-X fear and PANAS-X negative emotions (p <.0001, d = .94 and .83 respectively). There
was also a significant increase with a small effect size for PANAS-X attentiveness ((p <.05, d =
.39). There was also a significant increase in VAS-Anxiety with a medium effect size (p <.001, d
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 23
= .55). Nevermind (Therapeutic Skills). There was a significant decrease with a medium effect
size for DERS goals (p <.05, d = -.34), and no significant changes in CAMS-R scores.
In sum, the increase in serenity and decreases in VAS-Anxiety, fear, and negative
emotions for Blowing Blues suggests that this game is able to elicit most but not all of its
intended emotions; while the increases in VAS-Anxiety, fear, and negative emotions for
Nevermind suggests that this game is also able to elicit most but not all of its intended emotions.
The reductions in DERS goals and impulsiveness means Blowing Blues was able to impart some
therapeutic skills (though not the ones it was expressly created to teach); while the reduction in
DERS goals for Nevermind suggests that Nevermind was also able to impart therapeutic skills.
These results now allow for an analysis of factors that are associated with the change in these
outcomes.
Aim 2a: “High” and “Low” Expectation Group Differences (Experimental Manipulation)
Statistical Analysis. A mixed effects linear regression model was used to test for
condition effects of the game via a time by condition interaction (Table 2). For the regression
model “condition” refers to whether each participant was randomized to the “high expectation”
or “low expectation” condition.
There were two significant interactions for Blowing Blues and no significant interactions
for Nevermind. CAMS-R attention was significant for Blowing Blues (p <.05) such that those in
the “low expectation” condition experienced decreases in attention while those in the “high
expectation” condition experienced increases in attention (Figure 2a). For the simple effects, this
decrease in the “low expectation” group (Δ -2.70) was not significant (p = .08); the increase (Δ
2.72) in the “high expectation” group was not significant (p = .13). Thus, it appears that for
CAMS-R attention the rate of change provides more information than the scores themselves.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 24
DERS strategies also had a significant interaction for Blowing Blues (p <.001) such that those in
the “low expectation” condition experienced increases in strategies while those in the “high
expectation” condition experienced a reduction in strategies (Figure 2b). For the simple effects,
this increase in the “low expectation” condition (Δ – 2.11) was not significant (p = .08); the
reduction in strategies (Δ – 4.85) in the “high expectation” condition was statistically significant
(p < .01). Thus, it appears that the rate of change and the scores for DERS strategies after video
game play provide more information than DERS strategies scores prior to video game play. No
other interactions were statistically significant for Blowing Blues.
In sum, it appears the manipulation was largely ineffective at causing a change in the
outcome measures. However, since we collected a measures of motivation and expectancy at
pre- and post-game play it is still possible to evaluate how expectancy and motivation are
associated with changes in the outcomes, independent of the experimental manipulation.
Aim 2b: Associations of Expectancy and Motivation with Changes in Emotional Impact
and Therapeutic Skills
Statistical Analysis. In order to understand these associations, a two-fold approach was
taken. First, Pearson correlations with credibility, expectancy, and motivation were examined
with the outcomes at pre- and post-game play in order to determine if any of these were related
to concurrent levels of emotional impact and therapeutic skills. Second, a mixed effects linear
regression model was used to examine if the change in credibility, expectancy, or motivation
were associated with the change in these outcomes.
Emotional Impact: Blowing Blues. Credibility and expectancy were positively correlated with
PANAS-X positive emotions (r=0.42 to 0.54, p<0.01) and PANAS-X self assurance (r=0.35 to
0.38, p<0.05) at pre- and post-game play for Blowing Blues (Table 3a). Credibility was
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 25
significantly (p<0.01) associated with PANAS-X attentiveness at pre- (r=0.54) and post-game
play (r=0.52) while expectancy was only associated after playing Blowing Blues (r=0.45). There
were significant positive correlations between motivation PANAS-X positive emotions (r= .44, p
<.01), PANAS-X self-assurance (r= .35, p <.05), and PANAS-X attentiveness (r= .33, p <.05)
after video game play. However, greater change in credibility, expectancy, and motivation were
not associated with greater change in these PANAS-X outcomes. There were no significant
relationships between credibility, expectancy, or motivation and VAS-Anxiety at pre- or post-
game play. Changes in expectancy were significantly associated with changes in VAS-Anxiety
(p <.05) such that as expectancy increased, VAS-Anxiety decreased (Figure 3.1a). Change in
motivation was not associated with change in emotions.
Emotional Impact: Nevermind. There were no significant correlations between any of the self-
reported emotions and credibility or expectancy at pre-game play. However, at post-game play
there was a significant correlation of credibility and expectancy with PANAS-X positive
emotions and self-assurance (r=0.37 to 0.41, p<0.05) (Table 3b). Additionally, credibility was
associated with PANAS-X attentiveness at post-game play (r= .36, p <.05), while motivation was
associated at pre-game play (r= .30, p <.05). There was also a significant correlation between
motivation and PANAS-X positive emotions at pre- (r= .29, p <.05), and post-game play (r= .35,
p <.05). Changes in expectancy and motivation were both significantly associated with changes
in PANAS-X positive emotions (p <.05) such that positive emotions increased as expectancy and
motivation increased (Figures 3.1b & 3.2b). Changes in both credibility (p <.05) and expectancy
(p <.01) were significantly associated with changes in PANAS-X self-assurance such that self-
assurance increased as credibility and expectancy increased (figure 3.3b and 3.4b). There were
no significant relationships between credibility, expectancy, or motivation and VAS-Anxiety at
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 26
pre- or post-game play. Changes in credibility, expectancy, or motivation were not related to
changes in VAS-Anxiety.
Therapeutic Skills: Blowing Blues. Both credibility (r= 0.31 to 0.42, p <.05) and expectancy
(r= 0.36 to .47, p <.05) were significantly correlated with CAMS-R present focus at pre- and
post-game play. Credibility was significantly correlated with DERS awareness at pre- (r= -
.47, p <.01) and post-game play (r= -.40, p <.01) as well as with DERS goals at pre-game play
(r= .35, p <.05). Expectancy (r= -.33, p <.05) was significantly correlated with DERS awareness
at pre-game play. Motivation and CAMS-R present focus were associated at post-game play
(r=.29, p <.05). Additionally motivation was associated with DERS awareness (r= -.34 to -
.30, p <.05) and DERS goals (r=.33 to .36, p <.05) at pre- and post-game play. Changes in
credibility and expectancy were not associated with changes in therapeutic skills. Changes in
motivation were significantly associated with changes in DERS impulse (p <.01) such
that impulse increases as motivation increases (Figure 3.2a).
Therapeutic Skills. Nevermind. DERS awareness was significantly correlated with
credibility at pre- (r= -.34,p <.05) and post-game play (r= -.36, p <.05). There was a significant
correlation between motivation and DERS awareness (r= -.34) as well as DERS goals (r= -
.30) at pre-, but not post-game play (p <.05). Changes in credibility and expectancy were not
associated with changes in therapeutic skills. Changes in motivation were significantly associated
with changes in CAMS-R attention (p <.05) such that motivation and attention both increased
together (Figure 3.5b).
In sum, the results suggest that credibility, expectancy, and motivation all have
significant associations with many changes in outcomes related to emotions and therapeutic
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 27
skills. Given these associations, the next step is to analyze how they might mediate each other in
terms of changes to overall outcomes.
Aim 3 In-game Experience
Statistical Analysis. A mixed-effects linear regression was used to test for associations of flow
with changes in emotions and therapeutic skills.
Flow and Emotional Impact: Blowing Blues. Changes in PANAS-X serenity were
significantly associated with flow (p<.05) such that a higher level of flow brought higher levels
of positive change in serenity (Table 4). Additionally, higher levels of flow were associated with
greater reductions in VAS-Anxiety (p<.001). Figures 4a and 4b illustrate these relationships.
Flow and Emotional Impact: Nevermind. Changes in PANAS-X positive emotions and self-
assurance were significantly associated with flow (p<.05), such that higher levels of flow were
associated with greater increases in PANAS-X scores. Figures 4c and 4d illustrate these
relationships. Changes in VAS-Anxiety were not associated with flow for Nevermind.
Flow and Therapeutic Skills: Blowing Blues: Flow was associated with changes in
DERS impulsiveness (p=0.03), such that higher levels of flow were associated with greater
increases in DERS impulsiveness (Figure 4e)
Flow and Therapeutic Skills: Nevermind: Flow was not associated with changes in therapeutic
skills.
In sum, the results suggest that flow has significant associations with changes related to
the emotional impact of both games, and the therapeutic skills for Blowing Blues. Since some of
the changes in outcomes were associated with flow, flow will be included in the mediation
analysis.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 28
Aim 4: Mediation of Changes in Emotional Impact and Therapeutic Skills
A mediation model will be the final analysis undertaken. This analysis is meant to test
whether or expectancy can account for the associations between motivation, credibility, flow, and
changes in emotions and therapeutic skills.
Aim 4: Mediation of Changes in Emotional Impact and Therapeutic Skills
Statistical Analysis. In order to examine potential mediation of the effects of change
in expectancy by change in motivation or flow, a linear regression change score model was used.
These models were only explored when change in the outcomes were related to both expectancy
and flow or motivation separately. The model regressed the post-game play outcome on the pre-
game play outcome with the change score for expectation and change score for motivation or
flow level. These models were used to determine if either predictor was independently associated
with change in the outcome.
Mediation of Relevance by Expectation: For Blowing Blues, there were no common
outcomes where change in expectation or change in relevance predicted changes in the outcome,
thus mediation models were not explored. For Nevermind, both change in expectancy and change
in motivation were related to change in PANAS-X positive emotions and self assurance. When
modeled together only change in expectancy was statistically significant after adjustment for
change in motivation, potentially suggesting that the association of change in motivation to the
change in these PANAS-X scores is mediated by change in expectancy. An illustration of this
is depicted in Table 5a. The table shows that in the models with both expectancy and motivation
in them, only expectancy is significant
Mediation of Expectation by Flow: For Blowing Blues, change in VAS-Anxiety was
associated with change in expectancy and flow. When modeled together, only flow was
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 29
significantly associated with change in VAS-Anxiety, suggesting a possible mediation by flow.
Table 5b shows that in the model with both expectancy and flow, only flow is significant. For
Nevermind, both PANAS-X positive emotions and self assurance were related to the change
in expectancy and flow. For positive emotions, flow was statistically significant after adjustment
for change in expectancy. For self assurance, while expectancy was no longer statistically
significant at p<0.05, the attenuation in significance was minor and suggests that both change in
expectancy and flow are independently associated with change in self assurance. An illustration
of this is depicted in Table 5c. The table shows that in the models with both expectancy and flow
in them only flow is significant for positive emotions, but both appear to be independently
influencing changes in self assurance.
Independent Effects of Expectation: Lastly, for outcomes affected by change in
expectancy and credibility a regression model utilizing both variables simultaneously was fit to
determine which variable is the greater predictor of change in the outcomes (Table 5d). For
Blowing Blues, there were no common associations of credibility and expectancy with change in
the outcomes. For Nevermind, PANAS-X self assurance was significantly associated with
change in both expectancy and credibility. When modeled together, change in expectancy had the
greatest standardized coefficient, and though both variables were no longer statistically
significant, the attenuation in the significance for expectancy was minimal, suggesting that the
changes in PANAS-X self assurance are primarily driven by changes in expectancy rather than
credibility.
In sum, expectancy mediates the impact of motivation on some outcomes. Expectancy
also seems to be better at predicting positive changes than credibility. In relation to flow and
expectancy, self assurance seems to support an independent association, whereas positive
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 30
emotions seem to imply that flow mediates expectancy, so this relationship must be further
investigated. However, this mediation analysis supports the theory that factors outside of
motivation and self-determination can explain some of the changes the result from video game
play.
Discussion
Video games have a robust literature supporting their ability to evoke positive changes in
users (Granic, Lobel, Engles, 2014). SDT posits such changes are strongly related to the level of
agency one has in choosing the activity. Thus, video games benefit users because they are
predominately a leisure activity and mostly played by users intrinsically (i.e., the ultimate form
of autonomous action). The present study asserted that SDT overlooks aspects of change that are
unrelated to one’s motivation, specifically presenting expectancy as an area this model ignores.
The findings of this study seem to confirm the hypothesis that expectancy is associated with
changes related to video game play outside of one’s motivations.
The results of the study can be summarized as follows. Blowing Blues and Nevermind
were able to significantly change emotions and impart some therapeutic skills, and many of these
changes were the changes that each game targeted. Further, results showed that expectancy,
motivation, flow, and credibility were all significantly associated with many of these desired
changes in emotions and therapeutic skills. Finally, a mediation analysis revealed that expectancy
accounted for much of the association between motivation, credibility, and changes in outcomes.
Thus, it appears that in cases in which expectancy, and motivation, or credibility increase,
expectancy best explains subsequent changes in outcomes. An additional finding is that flow and
expectancy have some overlap, but seem to be largely independent of each other in relation to
associated changes. Consequently, the degree to which someone expects something to work in
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 31
the future is a more important component of expectation than how much they think it will work
or how logical it appears to be (i.e., credibility). This may be further supported by the fact that
this study’s manipulation failed to produce significant differences between expectation groups
because the manipulation was largely predicated on how much scientific evidence supports each
video game, which may have influenced credibility more than expectancy.
In light of the fact that more attention is being paid to the study of video games for
improvement of mental health outcomes, it is important that we study why these changes are
taking place. Many researchers have used SDT theory to explain the changes resulting from
video game play, however, due to the findings of this study, they may be over estimating the
impact of motivation on associated changes. Moving forward, research must place more
emphasis on uncovering mediators, moderators, and mechanisms of change in relation to the
positive benefits of video game play. Specifically, expectancy must be factor considered in these
studies (as well as flow). Without understanding the processes by which video games change
behavior, our ability to create optimally effective serious games in the future is limited because
we do not know what is causing change. Thus, emphasis may currently be placed on components
of a game that are less effective at galvanizing change than others. With the growing popularity
of utilizing video games for change, and their potential to increase access to mental health
services, the need to uncover factors related to why these games cause change is imperative.
Limitations
The findings of the present study must be considered in relation to how the following limitations
may have impacted results. First, this study lacked the appropriate sample size to conduct a
complete mediation analysis. An a priori power analysis was conducted prior to the study in
order to analyze a full mediation pathways and it was determined that a minimum of 128
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 32
participants would be needed to complete such analysis. For the present study only 49
participants enrolled, and of those only 47 played both video games. Thus, although we had the
sample required to conduct the present analysis, other potential mechanisms of change that may
influence results were excluded from this analysis. Most notably, the present study was unable to
factor how severity of clinical symptoms assessed at baseline (i.e., depression and anxiety) may
have impacted results. Second, all dependent variables in the study were measured via self-
report. This is potentially problematic because self-report measures can bias outcomes in many
ways (e.g., Schwarz, 1999). However, to assuage this problem only established, well-validated
scales were chosen as measurement tools in the current study. A third limitation is in the use of
two video games targeting different behavioral content. It may be preferable to compare games
aimed at evoking the same emotions or improving the same therapeutic skills. Yet, the
comparison of two different games in terms of design and target content allowed for a rich
juxtaposition of these mediating variables that would not have been otherwise possible.
Specifically, comparing two opposing games highlighted the importance expectations across
video game designs. Fourth, the present study only used study participants from a Psychology
subject pool, which may create selection effects and a sampling bias. The result of this bias may
be an additional limitation on the generalizability of the study. Finally, this study minimized and
eliminated the most powerful form of motivation, intrinsic motivation. Therefore, these results
about how expectancy impacts emotions and therapeutic skills via-a-vis motivation can only be
applied to extrinsically motivated activities. This is an important development because SDT
claims that motivation and self-determination will cause change across intrinsic and extrinsic
motivation, which this study seems to suggest is wrong. However, the power of intrinsic
motivations cannot be denied, thus, future work must evaluate expectations as they relate to
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 33
intrinsically motivated activities. There are also components of the SDT theory that could not be
measured, so this study is not meant to be applied to the full SDT model, just one of the main
components, motivation.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 34
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Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 40
Tables
Table 1: Pre- and Post-game play scores for emotional impact, therapeutic skills, expectancy, and motivation.
Blowing Blues Nevermind
Outcome N Pre-game Post-game P-value Cohen’s d N Pre-game Post-game P-value Cohen’s d
PANAS-X
Positive Emotions 46 40.9 ± 17.2 36.9 ± 18.9 0.07 -0.27 47 40.9 ± 16.4 41.1 ± 21.5 0.96 0.01
Negative Emotions 46 9.56 ± 12.64 5.95 ± 6.41 0.02* -0.36 47 10.8 ± 12.4 25.2 ± 20.2 <.01* 0.83
Fear 46 10.2 ± 14.7 5.4 ± 7.4 0.01* -0.38 46 10.4 ± 12.0 32.8 ± 25.7 <.01* 0.94
Self Assurance 46 31.8 ± 20.9 29.4 ± 22.5 0.28 -0.16 46 31.4 ± 20.9 29.3 ± 23.5 0.42 -0.12
Attentiveness 46 46.4 ± 19.0 42.1 ± 20.0 0.06 -0.27 46 47.5 ± 17.8 54.3 ± 21.6 0.01* 0.39
Serenity 46 63.4 ± 22.4 73.0 ± 21.6 <.01* 0.54 46 59.9 ± 25.7 31.6 ± 25.4 <.01* -1.16
VAS-Anxiety 47 31.4 ± 18.5 20.1 ± 12.2 <.01* -0.85 47 40.2 ± 19.4 52.7 ± 20.8 <.01* 0.55
DERS
Clarity 46 24.0 ± 15.6 25.4 ± 16.2 0.23 0.18 47 28.0 ± 18.1 29.1 ± 18.2 0.59 0.08
Nonacceptance 46 24.2 ± 21.6 20.9 ± 20.6 0.07 -0.27 45 23.2 ± 20.1 21.6 ± 21.6 0.22 -0.19
Goals 46 44.4 ± 25.2 40.0 ± 22.4 <.01* -0.38 47 46.9 ± 23.5 43.5 ± 24.2 0.02* -0.34
Impulsiveness 46 22.4 ± 20.5 18.0 ± 16.0 <.01* -0.43 47 21.2 ± 17.4 23.1 ± 20.4 0.17 0.21
Awareness 46 39.1 ± 19.8 39.3 ± 21.6 0.91 0.02 47 38.9 ± 20.6 40.9 ± 22.3 0.18 0.2
Strategies 46 23.4 ± 19.3 22.2 ± 17.8 0.33 -0.15 47 23.3 ± 20.3 25.2 ± 21.2 0.07 0.28
CAMS-R
Attention 46 55.8 ± 12.8 55.6 ± 14.3 0.87 -0.03 47 53.9 ± 12.1 54.0 ± 11.5 0.92 0.01
Present Focus 46 56.4 ± 14.2 56.5 ± 14.9 0.96 0.01 47 55.1 ± 13.1 54.6 ± 14.4 0.76 -0.04
Awareness 46 57.0 ± 17.9 57.9 ± 20.8 0.61 0.08 47 55.2 ± 19.3 56.1 ± 19.5 0.66 0.06
Acceptance 46 65.2 ± 15.6 66.4 ± 16.6 0.44 0.11 47 62.6 ± 19.6 62.3 ± 17.9 0.76 -0.05
Total 46 58.6 ± 11.0 59.0 ± 11.9 0.64 0.07 47 56.7 ± 11.9 56.7 ± 11.2 0.96 0.01
Credibility 47 53.2 ± 20.0 52.7 ± 25.4 0.84 -0.03 46 52.4 ± 18.5 41.9 ± 24.2 <.01* -0.45
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 41
Expectancy 47 47.2 ± 21.5 47.1 ± 26.2 0.96 -0.01 46 37.8 ± 20.0 33.6 ± 27.4 0.22 -0.18
Motivation 47 1.19 ± 1.29 1.31 ± 1.25 0.10 0.24 47 1.73 ± 0.73 1.72 ± 0.78 0.87 -0.02
Note: * p<.05
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 42
Table 2:
Experimental Manipulations Effects (i.e., “High Expectation” versus “Low Expectation”) on Changes in Outcomes
Blowing Blues Nevermind
Outcome N Coefficient of Interaction P-value N Coefficient of Interaction P-value
PANAS-X
Positive Emotions 47 -1.87 ± 4.40 0.670 47 -2.64 ± 5.03 0.5991
Negative Emotions 47 1.94 ± 2.98 0.514 47 -0.8 ± 5.1 0.8728
Fear 47 2.24 ± 3.72 0.547 47 -1.6 ± 7.1 0.8235
Self Assurance 47 3.91 ± 4.51 0.387 47 -6.025 ± 5.188 0.2454
Attentiveness 47 -0.91 ± 4.62 0.844 47 -5.15 ± 5.21 0.3232
Serenity 47 4.45 ± 5.23 0.395 47 1.1 ± 7.2 0.8833
VAS-Anxiety 47 -2.0 ± 3.9 0.620 47 8.14 ± 6.63 0.2198
DERS
Clarity 47 -1.27 ± 2.38 0.593 47 7.54 ± 4.08 0.0645
Nonacceptance 47 -2.34 ± 3.67 0.525 47 -2.081 ± 2.505 0.4063
Goals 47 -6.37 ± 3.33 0.056 47 2.70 ± 2.90 0.3523
Impulsiveness 47 -1.48 ± 3.09 0.633 47 2.789 ± 2.748 0.3101
Awareness 47 4.77 ± 3.11 0.125 47 2.04 ± 2.93 0.4865
Strategies 47 -7.03 ± 2.02 0.001* 47 1.59 ± 2.03 0.4337
CAMS-R
Attention 47 5.41 ± 2.34 0.021* 47 3.62 ± 2.80 0.1954
Present Focus 47 2.401 ± 2.699 0.374 47 -2.289 ± 3.442 0.5061
Awareness 47 1.056 ± 3.476 0.761 47 -2.60 ± 4.17 0.5323
Acceptance 47 3.364 ± 2.945 0.253 47 -2.96 ± 2.11 0.16
Total 47 3.09 ± 1.71 0.070 47 -1.058 ± 2.085 0.6117
Credibility 47 -1.890 ± 5.315 0.722 47 -8.97 ± 6.86 0.1905
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 43
Expectancy 47 2.93 ± 6.06 0.629 47 -7.612 ± 6.799 0.2629
Motivation 47 -0.087 ± 0.150 0.562 47 -0.087 ± 0.154 0.5707
Note: * p<.05
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 44
Table 3a. Associations of Credibility, Expectancy, and Motivation with emotions and therapeutic skills for Blowing Blues
Credibility Expectancy Motivation
Pre Post Interaction p Pre Post Interaction p Pre Post Interaction p
PANAS-X
Positive
Emotions *0.53 *0.54 -0.04 ± 0.12 0.76 *0.42 *0.49 -0.09 ± 0.11 0.40 0.16 *0.44 0.78 ± 4.36 0.86
Negative
Emotions -0.04 0.12 0.03 ± 0.08 0.75 0.05 0.06 0.03 ± 0.07 0.71 0.06 -0.01 5.06 ± 2.86 0.08
Fear -0.11 0.16 0.05 ± 0.10 0.61 0.01 0.12 0.03 ± 0.09 0.75 -0.01 -0.03 6.09 ± 3.57 0.09
Self Assurance *0.37 *0.35 0.09 ± 0.13 0.48 *0.38 *0.35 0.07 ± 0.11 0.51 0.18 *0.35 3.46 ± 4.47 0.44
Attentiveness *0.54 *0.52 -0.04 ± 0.13 0.77 0.25 *0.45 -0.08 ± 0.11 0.48 0.11 *0.33 4.70 ± 4.51 0.30
Serenity 0.14 0.13 0.21 ± 0.14 0.14 0.18 0.2 0.20 ± 0.12 0.11 -0.04 -0.04 3.57 ± 5.18 0.49
VAS-Anxiety 0.2 0 -0.2 ± 0.1 0.15 0.04 -0.06 -0.2 ± 0.1 0.02 0.19 0.01 -4.2 ± 3.9 0.28
DERS
Clarity -0.06 -0.18 0.01 ± 0.07 0.89 -0.13 -0.04 -0.02 ± 0.06 0.77 0.04 0.08 -2.11 ± 2.34 0.37
Nonacceptance 0.11 -0.16 0.08 ± 0.10 0.46 -0.08 0.04 0.09 ± 0.09 0.30 0.22 0.19 -0.10 ± 3.64 0.98
Goals *0.35 0.06 0.00 ± 0.10 0.98 0.24 0.15 0.05 ± 0.08 0.52 *0.36 *0.33 1.20 ± 3.42 0.73
Impulsiveness 0.08 -0.06 0.13 ± 0.08 0.12 -0.08 0.1 0.09 ± 0.07 0.22 0.16 0.1 8.33 ± 2.80 0.00
Awareness *-0.47 *-0.40 -0.12 ± 0.09 0.18 *-0.33 -0.27 -0.01 ± 0.08 0.86 *-0.34 *-0.30 1.14 ± 3.15 0.72
Strategies 0.06 0.07 0.05 ± 0.06 0.42 -0.02 0.14 -0.03 ± 0.06 0.60 0.07 0.19 2.29 ± 2.23 0.31
CAMS-R
Attention 0.17 0.28 0.10 ± 0.07 0.14 0.12 0.25 0.05 ± 0.06 0.36 -0.01 0.00 2.62 ± 2.42 0.28
Present Focus *0.42 *0.31 0.01 ± 0.08 0.91 *0.47 *0.36 0.03 ± 0.07 0.66 0.23 *.29 2.62 ± 2.66 0.32
Awareness 0.16 0.27 -0.04 ± 0.10 0.69 0.20 0.21 0.05 ± 0.08 0.53 0.01 0.01 -3.86 ± 3.40 0.26
Acceptance 0.07 -0.11 -0.03 ± 0.08 0.72 0.07 -0.13 0.02 ± 0.07 0.81 -0.09 -0.14 -1.14 ± 2.95 0.70
Total 0.27 0.26 0.010± 0.05 0.83 0.29* 0.23 0.04 ± 0.04 0.36 0.08 0.04 2.62 ± 2.42 0.28
Note: * p<.05

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 45
Table 3b. Associations of Credibility, Expectancy, and Motivation with emotions and therapeutic skills for Nevermind
Credibility Expectancy Motivation
Pre Post Interaction p Pre Post Interaction p Pre Post Interaction p
PANAS-X
Positive
Emotions 0.15 *0.41 0.14 ± 0.11 0.20 0 *0.37 0.235 ± 0.10 0.02 *0.29 *0.35 10.60 ± 4.62 0.02
Negative
Emotions 0.02 -0.19 -0.1 ± 0.1 0.35 -0.03 -0.14 -0.1 ± 0.1 0.26 0.22 -0.02 -6.5 ± 4.8 0.18
Fear 0.01 -0.07 -0.1 ± 0.2 0.67 -0.04 0.02 -0.1 ± 0.2 0.74 0.23 0.09 -2.0 ± 6.9 0.78
Self Assurance -0.01 *0.41 0.259 ± 0.11 0.02 -0.12 *0.41 0.32 ± 0.11 0.00 0.16 0.18 9.06 ± 4.87 0.06
Attentiveness 0.17 *0.36 0.18 ± 0.11 0.10 0.00 0.29 0.18 ± 0.11 0.10 *0.30 0.23 4.95 ± 4.99 0.32
Serenity 0.03 0.25 0.1 ± 0.2 0.61 -0.02 0.14 0.1 ± 0.2 0.71 -0.01 -0.04 1.9 ± 6.9 0.79
VAS-Anxiety -0.17 -0.28 -0.2 ± 0.1 0.13 -0.1 -0.17 -0.1 ± 0.1 0.33 0.26 0.09 6.6 ± 6.4 0.31
DERS
Clarity -0.16 -0.19 -0.04 ± 0.09 0.68 0.12 -0.03 0.01 ± 0.09 0.87 -0.03 -0.05 3.92 ± 4.05 0.33
Nonacceptance 0.01 0.01 0.01 ± 0.06 0.92 -0.01 0.02 -0.01 ± 0.06 0.84 0.15 0.13 -1.07 ± 2.39 0.65
Goals 0.29 0.10 0.08 ± 0.06 0.18 0.16 0.12 0.09 ± 0.06 0.16 *0.30 0.08 2.65 ± 2.80 0.35
Impulsiveness 0.03 -0.13 0.04 ± 0.05 0.45 0.13 -0.09 0.05 ± 0.05 0.36 0.15 0.12 3.42 ± 2.64 0.19
Awareness *-0.34 *-0.36 -0.08 ± 0.06 0.20 -0.06 -0.21 0.01 ± 0.07 0.87 *-0.34 -0.29 -2.97 ± 2.81 0.29
Strategies 0.04 -0.18 -0.00 ± 0.04 0.99 0.14 -0.12 -0.01 ± 0.05 0.84 0.12 -0.1 -3.20 ± 1.91 0.09
CAMS-R
Attention 0.23 0.19 0.07 ± 0.06 0.26 0.07 0.08 0.06 ± 0.06 0.33 -0.18 -0.02 5.61 ± 2.62 0.03
Present Focus 0.24 0.20 0.02 ± 0.08 0.81 0.18 0.21 0.05 ± 0.08 0.54 -0.18 -0.09 -0.510 ± 3.35 0.88
Awareness 0.18 0.09 0.08 ± 0.09 0.34 0.11 -0.02 0.10 ± 0.09 0.28 0.02 0.17 -1.73 ± 4.04 0.67
Acceptance 0.11 0.16 0.014 ± 0.05 0.77 -0.09 0.09 0.01 ± 0.05 0.90 -0.08 -0.12 2.69 ± 2.04 0.19
Total 0.24 0.22 -0.02 ± 1.75 0.99 0.08 0.12 0.04 ± 0.04 0.36 -0.12 -0.03 1.51 ± 2.01 0.45
Note: * p<.05

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 46
Table 4:
Associations of Flow with emotions and motivations for changes in emotions and therapeutic skills
Blowing Blues Nevermind
Outcome Coefficient of Interaction P-value Coefficient of Interaction P-value
PANAS-X
Positive Emotions 1.9 ± 2.5 0.4646 5.4 ± 2.1 0.0102*
Negative Emotions 1.81 ± 1.72 0.2909 -3.2 ± 2.2 0.1521
Fear 2.2 ± 2.1 0.299 -2.8 ± 3.2 0.3705
Self Assurance 2.2 ± 2.6 0.4048 5.5 ± 2.2 0.0124*
Attentiveness 3.1 ± 2.6 0.2355 0.63 ± 2.35 0.7895
Serenity 5.9 ± 2.9 0.0445* 1.7 ± 3.2 0.608
VAS-Anxiety -6.9 ± 2.1 0.0009* -1.0 ± 3.0 0.7301
DERS
Clarity
-0.50 ± 1.38 0.7183

-0.04 ± 1.89 0.9834
Nonacceptance
1.59 ± 2.12 0.4541

1.13 ± 1.11 0.3092
Goals
-1.62 ± 2.00 0.4182

0.95 ± 1.30 0.4651
Impulsiveness
3.7 ± 1.7 0.0301*

-0.66 ± 1.24 0.5944
Awareness
0.68 ± 1.85 0.7142

0.04 ± 1.31 0.9779
Strategies
0.50 ± 1.32 0.705

-0.98 ± 0.90 0.2737
CAMS-R
Attention 1.89 ± 1.41 0.1814 -1.01 ± 1.26 0.4223
Present Focus 0.72 ± 1.58 0.6481 -1.26 ± 1.53 0.4093
Awareness -1.58 ± 2.01 0.4307 -2.77 ± 1.82 0.1287
Acceptance -0.20 ± 1.74 0.9105 0.50 ± 0.96 0.6035
Total 0.193 ± 1.028 0.8508 -1.14 ± 0.92 0.2154
Note: * p<.05
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 47
Table
5a.

Mediation
of
Motivation
by
Expectancy
on
PANAS-‐X
Outcomes
(Blowing
Blues)

ΔPANAS-‐X
Positive
Emotions
ΔPANAS-‐X
Self
Assurance

b
±
SE
P-‐value
b
±
SE
P-‐value

Baseline
PANAS-‐X
0.697 ± 0.153 <.0001 0.647 ± 0.126 <.0001
Change
in
Expectancy
Z
Score
5.101 ± 2.302 0.0322 7.106 ± 2.344 0.0042
Change
in
Motivation
Z
Score
3.100 ± 2.400 0.2035 2.412 ± 2.338 0.3083
Note:
This
suggests
that
changes
in
positive
emotions
and
self-‐assurance
for
those
playing
blowing
Blues
was
better
accounted

for
by
the
extent
to
which
they
believe
the
game
will
help
them
as
opposed
to
how
motivated
they
are
to
learn
the
skill
of
the

game.

Table
5b.

Mediation
of
Expectancy
by
Flow
on
VAS-‐Anxiety

ΔVAS-‐Anxiety

b
±
SE
P-‐value

Baseline
VAS-‐Anxiety

0.507
±
0.068 <.0001
Change
in
Expectancy
Z
Score
-‐0.400
±
1.503 0.7915
Flow
Z
Score
-‐4.509
±
1.748 0.0134

Table
5c.

Mediation
of
Expectancy
and
Flow
on
PANAS-‐X
Outcomes
(Nevermind)

ΔPANAS-‐X
Positive
Emotions
ΔPANAS-‐X
Self
Assurance

b
±
SE
P-‐value
b
±
SE
P-‐value

Baseline
PANAS-‐X
0.599
±
0.140 0.0001 0.623
±
0.122 <.0001
Change
in
Expectancy
Z
Score
3.717
±
2.237 0.104 6.084
±
2.337 0.0128
Flow
Z
Score
5.965
±
2.238 0.0109 4.522
±
2.285 0.0546
Note:
This
suggests
that
they
are
independent
pathways,
and
both
play
into
changes
in
outcomes
in
their
own
way.

Table
5d.

Mediation
of
Credibility
by
Expectancy
on
PANAS-‐X
Self
Assurance
(Nevermind)

ΔPANAS-‐X
Self
Assurance

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 48

b
±
SE
P-‐value

Baseline
PANAS-‐X
0.638 ± 0.127 <.0001
Change
in
Expectancy
Z
Score
6.877 ± 3.505 0.0566
Change
in
Credibility
Z
Score
1.199 ± 3.373 0.7241
Note:
This
suggests
that
that
the
affective
or
“gut
instinct”
belief
one
has
in
the
video
game
explains
the
change
in
self-‐
assurance
better
than
their
cognitive
appraisal
of
how
effective
they
think
the
game
will
be.

Thus,
evidence
behind
a
game

may
not
be
as
important
as
the
personal
meaning
the
person
ascribes
to
the
game
in
relation
to
how
helpful
it
will
be
for
them.

This
finding
is
further
supported
by
the
failed
manipulation.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

49
Figures

Figure 2a.
Interaction for CAMS-R Attention by Experimental Condition for Blowing Blues
45
50
55
60
65
CAMS-R Attention
Pre-Play Post-Play
Time
Low Expectation High Expectation
Condition:

Note: The simple effects for this interaction were not significant.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

50

Figure 2b.
Interaction for DERS Strategies by Experimental Condition for Blowing Blues
15
20
25
30
35
DERS-Strategies
Pre-Play Post-Play
Time
Low Expectation High Expectation
Condition:

Note: The reduction in DERS strategies for the “high expectation” condition was statistically
significant.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

51

Figure 3.1a.
Association between changes in VAS-Anxiety and changes in Expectancy for Blowing Blues
-25
-20
-15
-10
-5
0
Change in VAS-Anxiety
-30 -20 -10 0 10 20 30
Change in Expectancy

Note: This association is statistically significant

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52

Figure 3.1b.
Association between changes in PANAS-X Negative Emotions and changes in Expectancy for
Nevermind
0
5
10
15
20
25
Change in PANAS-X Negative Emotions
-30 -20 -10 0 10 20 30
Change in Expectancy

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

53

Figure 3.2a.
Association between changes in DERS Impulsiveness and changes in Motivation for Blowing
Blues
-15
-10
-5
0
5
Change in DERS-Impulse
-.5 -.4 -.3 -.2 -.1 0 .1 .2 .3 .4 .5
Change in Motivation

Note: This association is statistically significant

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54

Figure 3.2b.
Association between changes in PANAS-X Positive Emotions and changes in Motivation for
Nevermind
-10
-5
0
5
10
Change in PANAS-X Positive Emotions
-.5 -.4 -.3 -.2 -.1 0 .1 .2 .3 .4 .5
Change in Motivation

Note: This association is statistically significant

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55

Figure 3.3b.
Association between changes in PANAS-X Self Assurance and changes in Credibility for
Nevermind
-15
-10
-5
0
5
10
Change in PANAS-X Self Assurance
-35 -25 -15 -5 5 15
Change in Credibility

Note: This association is statistically significant

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56

Figure 3.4b.
Association between changes in PANAS-X Self Assurance and changes in Expectancy for
Nevermind
-20
-10
0
10
20
Change in PANAS-X Self Assurance
-30 -20 -10 0 10 20 30
Change in Expectancy

Note: This association is statistically significant

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57

Figure 3.5b.
Association between changes in CAMS-R Attention and changes in Motivation for Nevermind
-5
0
5
10
Change in CAMS-R Attention
-.5 -.4 -.3 -.2 -.1 0 .1 .2 .3 .4 .5
Change in Motivation

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

58

Figure 4a.
Association between changes in PANAS-X Serenity and Flow for Blowing Blues
-20
-10
0
10
20
Change in PANAS-X Serenity
1 1.5 2 2.5 3 3.5 4
Flow

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

59

Figure 4b.
Association between changes in VAS-Anxiety and Flow for Blowing Blues
-20
-10
0
10
20
Change in VAS-Anxiety
1 1.5 2 2.5 3 3.5 4
Flow

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

60

Figure 4c.
Association between changes in PANAS-X Positive Emotions and Flow for Nevermind
-20
-10
0
10
20
Change in PANAS-X Positive Emotions
1 1.5 2 2.5 3 3.5 4
Flow

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

61

Figure 4d.
Association between changes in PANAS-X Self Assurance and Flow for Nevermind
-20
-10
0
10
20
Change in PANAS-X Self Assurance
1 1.5 2 2.5 3 3.5 4
Flow

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

62

Figure 4e.
Association between changes in DERS Impulsiveness and Flow for Blowing Blues
-20
-15
-10
-5
0
Change in DERS-Impulse
1 1.5 2 2.5 3 3.5 4
Flow

Note: This association is statistically significant

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES

63
Appendix

Positive and Negative Affect Scale – Expanded Form (PANAS-X)
This scale consists of a number of words and phrases that describe different feelings and emotions. Read each item and then mark the appropriate
answer in the space next to that word. Indicate to what extent you have feel these emotions right now (that is, at the present moment. Use the
following scale to record your answers:
1 100
Very slightly
or not at all
A
little
Moderately Quite a
bit
Extremely
________ Cheerful ________ Sad ________ Active ________ Angry at self
________ Disgusted ________ Calm ________ Guilty ________ Enthusiastic
________ Attentive ________ Afraid ________ Joyful ________ Downhearted
________ Bashful ________ Tired ________ Nervous ________ Sheepish
________ Sluggish ________ Amazed ________ Lonely ________ Distressed
________ Daring ________ Shaky ________ Sleepy ________ Blameworthy
________ Surprised ________ Happy ________ Excited ________ Determined
________ Strong ________ Timid ________ Hostile ________ Frightened
________ Scornful ________ Alone ________ Proud ________ Astonished
________ Relaxed ________ Alert ________ Jittery ________ Interested
________ Irritable ________ Upset ________ Lively ________ Loathing
________ Delighted ________ Angry ________ Ashamed ________ Confident
________ Inspired ________ Bold ________ At ease ________ Energetic
________ Fearless ________ Blue ________ Scared ________ Concentrating
________ Disgusted ________ Shy ________ Drowsy ________ Dissatisfied with
self
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 64

VAS-‐Anxiety
Scale

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 65

Credibility/Expectancy
Questionnaire
(CEQ)

We
would
like
you
to
indicate
below
how
much
you
believe,
right
now,
that
the
video
game
you

are
about
to
play
will
help
you
better
cope
with
your
emotions.

Belief
usually
has
two
aspects
to

it:
(1)
what
one
thinks
will
happen
and
(2)
what
one
feels
will
happen.
Sometimes
these
are

similar;
sometimes
they
are
different.
Please
answer
the
questions
below.

In
the
first
set,
answer
in
terms
of
what
you
THINK.
In
the
second
set,
answer
in
terms
of
what

you
really
and
truly
FEEL.

Set
I

1.
At
this
point,
how
logical
does
the
video
game
you’re
about
to
play
seem
to
you?

1
2
3
4
5
6
7
8
9

Not
at
all
logical
Somewhat
Logical
Very
Logical

2.
At
this
point,
how
successful
do
you
think
the
video
game
will
be
in
helping
you
cope
with
your

emotions?

1
2
3
4
5
6
7
8
9

Not
at
all
useful
Somewhat
useful

Very
useful

3.
How
confident
would
you
be
in
recommending
this
treatment
to
a
friend
who
needs
help

coping
with
emotions?

1
2
3
4
5
6
7
8
9

Not
at
all
confident
Somewhat
confident
Very
confident

4.
After
playing
the
video
game,
how
much
improvement
in
your
emotional
coping
do
you
think

will
occur?

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

Set
II

For
this
set,
close
your
eyes
for
a
few
moments,
and
try
to
identify
what
you
really
FEEL
about
the

video
game
and
its
likely
success.
Then
answer
the
following
questions.

1.
At
this
point,
how
much
do
you
really
feel
that
therapy
will
help
you
to
reduce
your
trauma

symptoms?

1
2
3
4
5
6
7
8
9

Not
at
all

Somewhat
Very
useful

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 66

2.
By
the
end
of
the
therapy
period,
how
much
improvement
in
your
trauma
symptoms
do
you

really
feel
will
occur?

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 67

Cognitive and Affective Mindfulness Scale-Revised (CAMS-R)
People have a variety of ways of relating to their thoughts and feelings. For each item below,
rate how much each of these ways applies to you
1
-‐-‐-‐-‐
2
-‐-‐-‐-‐
3
-‐-‐-‐-‐
4

Rarely/
Not at all
Sometimes

Often Almost
Always

1._________ It is easy for me to concentrate on what I am doing.
2._________ I am preoccupied by the future.
3._________ I can tolerate emotional pain.
4._________ I can accept things I cannot change.
5._________ I can usually describe how I feel at the moment in considerable detail.
6._________ I am easily distracted.
7._________ I am preoccupied by the past.
8._________ It’s easy for me to keep track of my thoughts and feelings.
9._________ I try to notice my thoughts without judging them.
10. _______ I am able to accept the thoughts and feelings I have.
11. _______ I am able to focus on the present moment.
12. _______ I am able to pay close attention to one thing for a long period of time.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 68

Difficulties in Emotion Regulation Scale (DERS)
Indicate how the following items apply to you right now.

1
-‐-‐-‐-‐
2
-‐-‐-‐-‐
3
-‐-‐-‐-‐
4
-‐-‐-‐-‐
5

Very
slightly

or
not
at
all

A
little

Moderately
Quite
a
bit
Extremely

1._________ I am clear about my feelings.
2._________ I pay attention to how I feel.
3._________ I experience my emotions as overwhelming and out of control.
4._________ I have no idea how I am feeling.
5._________ I have difficulty making sense out of my feelings.
6._________ I am attentive to my feelings.
7._________ I know exactly how I am feeling.
8._________ I care about what I am feeling.
9._________ I am confused about how I feel.
10. _______ When I’m upset, I acknowledge my emotions.
11. _______ When I’m upset, I become angry with myself for feeling that way.
12. _______ When I’m upset, I become embarrassed for feeling that way.
13. _______ When I’m upset, I have difficulty getting work done.
14. _______ When I’m upset, I become out of control.
15. _______ When I’m upset, I believe that I will remain that way for a long time.
16. _______ When I’m upset, I believe that I’ll end up feeling very depressed.
17. _______ When I’m upset, I believe that my feelings are valid and important.
18. _______ When I’m upset, I have difficulty focusing on other things.
19. _______ When I’m upset, I feel out of control.
20. _______ When I’m upset, I can still get things done.
21. _______ When I’m upset, I feel ashamed with myself for feeling that way.
22. _______ When I’m upset, I know that I can find a way to eventually feel better.
23. _______ When I’m upset, I feel like I am weak.
24. _______ When I’m upset, I feel like I can remain in control of my behaviors.
25. _______ When I’m upset, I feel guilty for feeling that way.
26. _______ When I’m upset, I have difficulty concentrating.
27. _______ When I’m upset, I have difficulty controlling my behaviors.
28. _______ When I’m upset, I believe that there is nothing I can do to make myself feel better.
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 69
29. _______ When I’m upset, I become irritated with myself for feeling that way.
30. _______ When I’m upset, I start to feel very bad about myself.
31. _______ When I’m upset, I believe that wallowing in it is all I can do.
32. _______ When I’m upset, I lose control over my behaviors.
33. _______ When I’m upset, I have difficulty thinking about anything else.
34. _______ When I’m upset, I take time to figure out what I’m really feeling.
35. _______ When I’m upset, it takes me a long time to feel better.
36. _______ When I’m upset, my emotions feel overwhelming.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 70

Flow State Scale (FSS)
Please answer the following questions in relation to your experience while playing the video
game. These questions relate to the thoughts and feelings you may have experienced during
game play. There are no right or wrong answers. Think about how you felt during the game and
answer the questions using the rating scale below. Circle the number that best matches your
experience from the options to the right of each question.
1
Strongly
Disagree
2 3
Neutral
4 5
Strongly Agree
1. I was challenged, but I believed my skills would allow me to
meet the challenge.
1 2 3 4 5
2. I made the correct moves without thinking about trying to do
so.
1 2 3 4 5
3. I knew clearly what I wanted to do. 1 2 3 4 5
4. It was really clear to me that I was doing well. 1 2 3 4 5
5. My attention was focused entirely on what I was doing. 1 2 3 4 5
6. I felt in total control of what I was doing 1 2 3 4 5
7. I was not concerned with what others may have been thinking
of me.
1 2 3 4 5
8. Time seemed to alter (either slowed down or speeded up). 1 2 3 4 5
9. I really enjoyed the experience. 1 2 3 4 5
10. My abilities matched the challenge of the situation 1 2 3 4 5
11. Things just seemed to be happening automatically. 1 2 3 4 5
12. I had a strong sense of what I wanted to do. 1 2 3 4 5
13. I was aware of how well I was performing. 1 2 3 4 5
14. It was no effort to keep my mind on what was happening. 1 2 3 4 5
15. I felt like I could control what I was doing. 1 2 3 4 5
16. I was not worried about my performance during the event. 1 2 3 4 5
17. The way time passed seemed to be different from normal. 1 2 3 4 5
18. I loved the feeling while playing the game and want to
capture it again.
1 2 3 4 5
19. I felt I was competent enough to meet the high demands of
the game.
1 2 3 4 5
20. I performed automatically. 1 2 3 4 5
21. I knew what I wanted to achieve. 1 2 3 4 5
22. I had a good idea while I was playing about how well I was
doing.
1 2 3 4 5
23. I had total concentration. 1 2 3 4 5
24. I had a feeling of total control. 1 2 3 4 5
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 71

25. I was not concerned with how I was presenting myself. 1 2 3 4 5
26. It felt like time stopped while I was playing. 1 2 3 4 5
27. The experience left me feeling great. 1 2 3 4 5
28. The challenge and my skills were at an equally high level. 1 2 3 4 5
29. I did things spontaneously and automatically without having
to think.
1 2 3 4 5
30. My goals were clearly defined. 1 2 3 4 5
31. I could tell by the way I was performing how well I was
doing.
1 2 3 4 5
32. I was completely focused on the task at hand. 1 2 3 4 5
33. I felt in total control of my body. 1 2 3 4 5
34. I was not worried about what others may have been thinking
of me.
1 2 3 4 5
35. At times, it almost seemed like things were happening in
slow motion
1 2 3 4 5
36. I found the experience extremely rewarding. 1 2 3 4 5
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 72

Demographics
Variable (N) Percentage
Sex
Male (26) 59.09
Female (21) 40.91
Marital Status
Single (42) 95.45
Other (02) 04.55
Ethnicity
White (20) 45.45
Asian (19) 43.18
Black (02) 04.55
Multiracial (03) 06.82
Education
High School Diploma / GED (12) 27.27
Some College (30) 68.18
Associates Degree (02) 04.55
Family Income
Less than $14,999 (01) 02.27
$15,000 - $24,999 (03) 06.82
$25,000 - $34,999 (00) 00.00
$35,000 - $44,999 (02) 04.55
$45,000 - $54,999 (02) 04.55
$55,000 - $64,999 (02) 04.55
$65,000 - $74,999 (04) 09.09
$75,000 or more (30) 68.18

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 73

Baseline Clinical Scores
Variable (N) Percentage
Depression
None (18) 40.91
Mild (16) 36.36
Moderate (08) 18.18
Moderate / Severe (02) 04.55
Anxiety
None (18) 40.91
Mild (17) 38.64
Moderate (09) 20.45

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 74
Video Game #1: Blowing Blues. Blowing Blues is a single-player game designed to help one relax and meditate by having them focus on, and “blow
away”, personal life stressors. The game was designed based on several core principles of mindfulness, and is played on any laptop or desktop computer
and works by turning a laptop’s microphone into a wind-sensor that can register how hard or soft a player is blowing into the microphone. Players are
asked to enter stressors from their lives they would like to meditate about. Once the stressors have been entered the game brings the player into the level
in which active meditation occurs (Image 2). In this level the stressors appear on the screen. Users are then supposed to scan their body and think about
any physical sensations the stressor evokes, take a deep breath in and out, blowing into the microphone during exhalation, and then scan their body and
once again pay attention to any sensations. The microphone registers this breath and literally blows the stressor away on the screen. Once the stressor
disappears another one will appear after a few seconds. The user repeats this process until the level ends, which is typically 10-15 minutes. In this study,
participants completed two levels and were instructed to enter a minimum of three personal stressors for each level. Relaxing music is played throughout
the game. A script of the instruction on how to play this game can be found in the appendix.
Image 2: Screen shot of Blowing Blues with the stressor of “anxiety” as the blow-away target

Image courtesy of Xuan Li
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 75
Given the mindfulness and relaxation components built into Blowing Blues, it is expected that those who play Blowing Blues will show an
increase in PANAS-X Positive Emotions, Attention, and Serenity, and CAMS-R mindfulness, while experiencing a decrease in Negative Emotions and
VAS-Anxiety. DERS is not expected to change in emotion regulation is not a skill explicitly targeted by the video game.
Video Game #2: Nevermind. Nevermind is a single player game in which the user works for a hypothetical company that enters subconscious minds of
trauma victims and attempts to recover a repressed traumatic memory. The person who enters the victims mind is called a “neuroprober”, and by
exploring the various rooms of the victims’ childhood home and solving a series of puzzles, the player collects Polaroid images. After collecting a total
of 10 Polaroid images, the user must place 5 of the images in a sequential order that tells the complete story of what happened to the victim. The
repressed memories are meant to be traumatic so the graphics, music, and tone of the game are dark and often fear-inducing (Image 3).
Image 1: Screenshot from Nevermind showing the "Kitchen" area of the game displaying milk being
interchanged with blood, and blood covering the refrigerator door.

Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 76
Image courtesy of Erin Reynolds.

As the person plays the game, they wear a heart-rate monitor that feeds into the game and continually measures the players Heart Rate Variability
(HRV). If the person’s HRV decreases, indicating increase sympathetic nervous system arousal, the game will prevent them from advancing until they
manage to slow their heart rate and increase their HRV. This real-time biofeedback underscores the central theme of the game, which is to help people
learn to control their heart rate when it is accelerating.
Nevermind was made with the central premise of creating a sense of self-control and self-efficacy for the user. This is accomplished by giving
the user real-time biofeedback, and teaching them that when they are fearful, frustrated, or angry, and if their heart rate increases (which prevents them
from advancing further into the game) they are the ones who will ultimately be able to calm themselves down. The dark and often morbid imagery
within the game is meant to illicit fear, while the challenging puzzles are meant to evoke anger and/or frustration; all of which are excitatory emotions
that increase one’s heart rate (Ekman, Levenson, & Friesen, 1983; Jost, 1941; Levenson, 1992). Consequently, one is given ample practice slowing
down their heart rate throughout the game. Evidence in support of Nevermind’s potential efficacy comes from two sources. First, Nevermind contains
the most fundamental component of Stress Inoculation Training (SIT). The central premise of SIT rests in its inoculation component, which calls for
one to be exposed to a stimulus strong enough to elicit defensive mechanisms, yet not so strong as to overwhelm the individual (Barlow, 2007a;
Meichenbaum, 1975a, 1975b, 1993). Inoculation is a key component in therapy for several psychological disorders including Panic Disorder,
Agoraphobia, and Social Anxiety Disorder (Barlow, 2007b). In SIT, allowing individuals an opportunity to experience and successfully deal with minor
stressors increases resilience and bolsters psychological preparedness and coping mechanisms (Barlow, 2007a). One feature of SIT that makes it
particularly appealing for video game adaptation is how flexibly it can be implemented (Barlow, 2007a). SIT has been used in a variety of contexts such
as surgery preparation (Langer, Janis, & Wolfer, 1975), chronic medical conditions and recurrent mental illness (Turk, Meichenbaum, & Genest, 1983)
as well as anxiety, anger, and pain (Meichenbaum, & Turk, 1976; Novaco, 1979). Moreover, SIT can vary in length from one 20 minute session (Langer
Running Head: VIDEO GAMES AND MENTAL HEALTH OUTCOMES 77
et al., 1975) to 40 one-hour sessions (Turk et al., 1983). Nevermind contains the core components of SIT by providing the player with in vivo
inoculation practice, which allows the user to self-regulate their negative emotions in a safe and non-threatening environment.
Given the strong foundation of several therapeutic principles, playing Nevermind is expected to reduce DERS scores since these are the skills
targeted by the video game. Mindfulness is not expected to change. Further, since the game is horror-themed and based on exposure principles, it is
expected to increase PANAS-X Fear, Negative Emotions, and VAS-Anxiety. However, since it’s supposed to help emotion regulation it is expected that
PANAS-X Self Assurance will increase.

Abstract (if available)

Abstract Self Determination Theory (SDT) has been used to explain the benefits observed from video game play. However, this theory may over-rely on the role of motivation and self-determination in behavior change. The present study investigated how expectations may influence behavior change from video game play and hypothesized that changes in outcomes from pre- to post-play would not be accounted for only by motivation and self-determination as SDT claims. To accomplish this, 47 participants were recruited to play two video games for mental health. In order to isolate the impact of expectations, participants were randomized to a “high expectation” or “low expectation” condition in which the “high expectation” group was told about the scientific evidence supporting the benefit of these specific games, and the “low expectation” group was told there is no evidence to suggest these games work. Expectations about how helpful the game will be and their motivation to play were assessed before and after each game, as well as changes in emotions and therapeutic skills the game was meant to teach. Changes in expectations and motivation were then correlated with changes in outcome measures, after which a mediation model was used to assess whether expectations or motivations were more responsible for observed changes. Flow was also measured after video game play to measure in-game enjoyment. Results found that expectations, flow, and motivation were all significantly associated with the changes in emotions and therapeutic skills that each game was targeting. A mediation analysis revealed that expectations mediated the impact of motivations on outcomes, and flow meditated some, but not all of the impact of expectations on outcomes. Taken together, the results of the study add to a growing body of literature demonstrating video games’ potential aid in improving mental health, especially over a short period of time. Further, these results suggest that SDT may be over-estimating the role of motivation and self-determination as agents responsible for changes in one’s growth and development. Specifically, this study found that expectations akin to the placebo effect may in fact be responsible for some of the changes currently being attributed to SDT. Future studies are encouraged to investigate the full extent of the relationships between expectations, flow, and motivation.

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Asset Metadata

Creator Newell, Jeffery A. (author)

Core Title The emotional and therapeutic impact of video games for health: Is motivation to improve more important than expectations for improvement?

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 09/17/2015

Defense Date 05/29/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag expectations,games for health,low-intensity interventions,mediation,OAI-PMH Harvest,self-determination theory,video games

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lopez, Steven R. (committee chair)

Creator Email janewell@usc.edu,Jeffanewell@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-185368

Unique identifier UC11276106

Identifier etd-NewellJeff-3933.pdf (filename),usctheses-c40-185368 (legacy record id)

Legacy Identifier etd-NewellJeff-3933.pdf

Dmrecord 185368

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Format application/pdf (imt)

Rights Newell, Jeffery A.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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