 Thank you all for coming. I'm Les from New Mexico, USA. I've been in Second Life since sometime in mid-2008. I've been fortunate enough to make many great friends and consider myself blessed because of it. I find SL to be very therapeutic and it is the main social interaction that I have in any life. Thank you, Lyndon Lab. I have been living with a disability for 20 years, but that's okay. Thanks to doctors and friends, both in real life and Second Life, I'm doing okay. In real life, I'm disabled from the medical field. Oops, excuse me. I was able to have two great careers before I eventually became unable to work. Since then, one of the things I cherish about Second Life is that it has made me feel productive again. Feeling productive is great for the health of anyone, disabled or not, so I thank you, Lyndon Lab, for this great forum. I am retired, disabled from the medical field and most of my time is spent taking care of my mother. She was diagnosed three years ago with liver disease, so we both sort of take care of each other. Here in SL, I enjoy sailing and flying. I'm also a very proud member of the Second Life Coast Guard. We've been around since 2005, which is quite a feat in itself. Today, I'd like to introduce our next speaker, Dr. Michelle Calder-Carris. Dr. Carris is a mental health researcher who is interested in video games and how they can promote mental health and even prevent suicide. Dr. Carris is a gamer herself. Today, Dr. Carris will talk with us about how the games we participate in improve or hinder our well-being. She will tell us about problematic gaming, privacy issues, and how gaming disorders overlap with other problematic behaviors. Since Dr. Carris is new to Second Life, I'd like to request that our audience hold their comments and questions until she is done speaking. There will be time for a question and answer at the end of her session. Thank you. Please now welcome Dr. Michelle Carris. Good afternoon, everyone. I'm Michelle Calder-Carris, and I'm a public health researcher who specializes in video games and mental health. I'm really excited to be talking with you all today, and I look forward to your questions, and I'm happy to bear with me until the end to answer them. Aside from the standard disclaimer that the various organizations I've worked with prefer, I believe in talking about my intellectual conflict of interest. Although I haven't had any financial relationships with the video game industry, I do consider myself a gamer, although not as much lately. I have a disability, bipolar disorder, which I've lived with for about 35 years, and my research is driven by my firsthand experience and my experience as a family member. I have a deep personal connection with games and virtual worlds, and how they can both help and hinder mental health. Now, when people talk about games, there's often a lot of disagreement or confusion. In this presentation, I'll cast a really wide net and use the term video game to define lots of different types of interactive digital entertainment. So this is not strictly correct. I'm not going to describe games specifically as the way that we think about them from a scientific perspective, as having rules in a goal. But I'll include things like games that help you to be motivated to exercise, digital board games, virtual worlds, or simulations, and gambling type games. So all of these things you see, I am lumping together for the purposes of this presentation as games. And I'm going to ask you to think of it as games as a form of interactive digital entertainment that has playful elements. Now, my background is in the biomedical sciences, particularly in public health. And unfortunately, from a public health perspective, video games are often thought of as a negative exposure that leads to health problems. They don't have a good reputation. And this doesn't take into account that people play for different reasons and they have different motivations. And that the way that they interact with games or virtual worlds leads to what we call emergent properties. And that makes it impossible to investigate what we always want to investigate in science and particularly in public health. What is the X that causes Y? And while this is a common problem in public health, like what is the pathology that causes measles or Ebola, so how can we prevent that pathology? It's even harder in games because by their very nature, they change as people interact with them and as we make choices within the games. So thinking of them as a simple exposure doesn't make sense. And our understanding of the effects of games is also limited by the fact that the way people play games occurs within a context. It depends on which games they have access to, who they play with, what other activities they may be giving up and the impact of that game's context. And like we talked about earlier in the panel, the changing pace of technology also makes it hard to keep up. Not just from trying to understand the social context, but also just the new things that are coming down the line as researchers, especially in public health if there is something that could affect health, we want to be prepared. We want to know what we can do to ensure the population health. And because technology changes so fast it's really difficult to figure out how to keep up. In a little over 40 years, we've gone from Pong, a black and white TV-based game to taking games and virtual environments into the real world like Pokemon Go or becoming a valued member of an online global community whether it's in a game or a sim. And video games are wildly popular entertainment. So to compare, last year's Eagles Patriots Super Bowl had over 100 million viewers and that same year the 2018 League of Legends World Championship which was live streamed on Twitch had 99 million viewers. Some of the more popular video games such as Fortnite have 125 million players. PUBG, Player Unknown's Battlegrounds has 400 million players. Almost half of the United States plays regularly. Younger people play more than older ones. 72% of younger people versus about 49% of older people. 90% of teenagers play video games regularly. And we talked earlier about identification about a third of men identify as gamers but that number is much smaller for women only about 9%. People play games because they're fun and exciting and they keep playing because they're engaged. In public health we talk about the importance of meeting them where they're at. If we want to improve the health of a population or a group of people by giving them some kind of intervention we can't expect them to come to us. We have to go out into the community. In the olden days that might have meant on the playground like where these kids are playing capture the flag. And social interactions at that time were mostly face to face. That meant that people had to navigate a lot of difficult situations that favor those who have good social skills or who conform to social norms. This is what capture the flag is today. Today people spend hours a day online or even say they're always connected. Multitasking is the norm. This applies to people all over the globe. Not just those countries where most people have access to high speed broadband. Young kids now are the first generation who'll grow up with the norm of being constantly connected through online communication. A recent survey by the Pew Internet Research Center in the US found that 45% of teens said that they were constantly connected. For all of us connection combined with a blending of online spaces entertainment and marketing means that many people get their information through online media and we've learned how easily this information and even popular opinion can be manipulated. Multitasking has become the norm which has led to concern about how our attention is being divided. The good news is that these vast changes have leveled the playing field in many respects. These online digital spaces make it possible for people to participate in society and meet like-minded others when doing so in real life can be challenging. So if we want to change the health of populations we need to meet them where they're at which is online. Now social interactions are not my area of expertise as they are Nick's except in how they compare to the requirements and traditions of social interactions in public health programs. Some aspects are the same but many aspects are different. For example there are many more ways to have synchronous interactions with people at the same time rather than say writing a letter. Now we can have private or open conversations in different online settings have video conferences with multiple forms of media at the same time and communicate with thousands of people at the same time. We can still have asynchronous online communication through emails comments and discussion but the speed with which information ideas, opinions and support can flow ridiculously different. We also have anonymity and choice. In the real world there aren't a lot of opportunities to express your different embodiments of yourself. Here this is one of my favorite picks in the lower right. We have a bunch of video game fans dressed in cosplay costumes. These folks have come to a gaming con or convention called magfest to meet with other fans and enjoy the chance to step outside of their usual personas for a few days. That was me when I got back into video gaming in 2010. I cosplayed as one of the characters in my favorite dance video game. Well no that picture isn't exactly me but yes I did cosplay. In online worlds we have a lot more choice. When we talk about health interventions and programs we talk about scale and direction. How many people can we reach? If we intervene is it best to do it one on one or should we have some kind of program where we do one to many like an emergency alert system? Do we need feedback or reporting from many people to one person or a group like doctors reporting on new cases of measles for example to the public health department or is it best to have many people talking to many people like a support group? All of these modes are a lot easier to implement in online settings. Anonymity may be everyone's biggest concern. The anonymity provided by computer based communications is one of the biggest potential benefits. It can allow people to feel more free to express themselves to convide and this can allow people to form close relationships and receive real support. It leads to different types of communities and unique cultures. But that also has a downside. How anonymous are we really? There's no easy answer. I feel like that could be an entirely different presentation. One of the main things I'm hoping you'll take away from this is that commercial video games are so engaging that they can possibly improve our retention in therapy if we use them as interventions. Here's the way I look at it. We have the individual existing in their social context. That's the middle part of that diagram. With their unique life experiences their states of health and their health behaviors. The next step to the right they choose games purposefully. They're not exposed to games. Purposefully. And enjoy an immersive experience that involves different types of social interactions like teamwork. When people interact with games this generates data. Some of the data is publicly available. Some if we were to analyze it we would need to cooperate with game developers. We can mine that data. And through machine learning we could figure out how to use the data to identify health conditions and needs even in the moment. Then we can provide health services and interventions in these online settings where people are already spending their time. And I'll get back to that in a moment. But first whoops I wanted to give a brief review of existing game based interventions. So making sure yes okay. Games in North Carolina randomized people with clinical depression into groups. They asked one group to play Bejeweled 3 sorry Bejeweled 2 3 times a week for a month and the other group to surf a website about depression. The group that played video games had a significant reduction in their depression compared to the group that just learned about depression from a website. Another group of researchers in Sweden are investigating how to use Tetris as a cognitive vaccine to prevent PTSD. So far they've found that it reduces intrusive thoughts when given to people who've just had a motor vehicle crash or an emergency caesarean section. And I just noticed that I said when given to people and that kind of reflects my public health background I'm still thinking of giving a game to a person as if it's a therapy. Now Tetris is a much simpler game with fewer emergent properties than for example, Second Life or World of Warcraft. But you can still see where if you give people Tetris maybe they'll have a very frustrating experience. But maybe that doesn't matter. We don't know that. Games are also effective when given to children who are put in anxiety provoking situations like surgery or chemotherapy. They can really help reduce that anxiety. They can also be used in psychotherapy to develop rapport with patients or to learn more about their perspectives or the ways that they cope with things. The simple game of Solitaire can be used to monitor cognitive impairment of people with dementia or other forms of cognitive decline. By mapping errors and moves in the game to specific cognitive skills. However, there's one problem with these really fascinating studies. So far they're all very small even though these games offer the possibility of being used as therapy at a large scale, like the scale of the internet. There haven't been any large clinical trials yet. So we really don't have good confirmation that these could be therapeutic. My personal experience with online gaming and specifically with belonging to a guild in World of Warcraft made me interested in how guilds and other online communities could be useful to veterans. I was in a guild called F-List that was run by a veteran and he really liked to reproduce the militaristic setting that he felt comfortable in. The problem with games and other online settings is that different types of people conform to them. And he didn't restrict the guild to veterans or to people who conform to the rules that he had set for the guild. So, like we talked about in the panel people behave in the same types of ways. They behave offline and we had a young teenager who was just being obnoxious and that got my veteran leader really upset. And the fact that he was so drawn to the benefits of belonging to this guild and that he really appreciated what that militaristic structure gave him made me think about how therapeutic could that be as a transitional space for veterans who are returning from deployment. So, a couple of years ago I worked with a psychologist at a Veterans Affairs Medical Center on a qualitative study of how veterans used video games. We recruited veterans who were being treated for mental health problems or addiction who played video games for seven or more hours a week, which is about average. The average age of our gamers was about 40. We ended up with 20 individuals. And we asked them questions about their video game play habits, their user experience in the games, and the social dimensions of their gaming. Oh, also about their military experience and their mental health, like what draws you to video games? When you're playing, what makes you decide to stop? Have you ever been a member of a guild or a clan? What was that like? How, if at all, do you feel your diagnosis is related to video gaming, either in a positive or a negative way? Has gaming helped you cope with your diagnosis or manage your symptoms? How? And it's interesting, as a researcher, I find that I don't want to use a cliche, but of course the cliches are what come to mind. The first speaker, Kali, I believe her name was, she and I ended up taking a similar approach, right? We were both interested in how games could be useful for people who have conditions that they're dealing with. So it's heartening that she and I are both coming from a medical perspective and starting to look at the same research topic. Yes, so I also asked, has gaming caused you any problems related to your diagnosis? Oh, one more important point. I had many excellent collaborators on this and Nick Bowman, who just spoke and was on the panel earlier, his partner Jamie is a really important part of this and she helped come up with this these questions and do the qualitative analysis. One that some people indeed used games to escape or provide relief from disturbing or uncontrollable negative thoughts and feelings. Others used games to develop meaning in their lives through opportunities for leadership or employment or even through reframing the difficult choices that they had to make such as in the line of fire. Many found games really important for connecting and some of this I'm telling you and I feel like I don't have as this but I present my research elsewhere and people who don't understand virtual worlds they find this amazing and fascinating. For one young man who had severe PTSD connecting with his twitch followers was the only way he felt comfortable in social settings and he really connected through that military the military aspect of his gaming another vet had some difficult decisions to make during his military service. To him the game life is strange resonated strongly because it had a compelling narrative and the ability to control time or rewind it as you see there it occurs to me that it would be useful to read the slide text but of course let me see I'm gonna I'm going to try to rotate my view I know I can do it so for the veteran with PTSD the quote from my study is I've met a bunch of active duty infantry guys online and we play specific combat games together we all know the lingo and it's awesome for the gentlemen who liked the game life is strange the main part of his comment is like if you make a decision and your friend got killed you get to pull it back make a different decision and see if they die or not but the thing that was most striking to me is how people talked about the power of games to get them through the hardest points in their lives gamers were using them as tools to refocus or cope when nothing else is available they kept the mind busy I was so excited because in qualitative research metaphors can be really important and I heard two different people talk about idle hands being the devil's workshop so one individual talked about how games help with refocusing because they give you tools to do these in treatment but when you're in the midst of all that chaos you're not thinking about tools your brain has the time to stop quivering another gentleman said that he tells guys in recovery and guys who have depression you just can't go to meetings you just can't take medication you gotta find something to do to fill those spaces in when you got the time to think of the devil's workshop we even found that for some vets it was an effective way to avoid substance use relapse one woman wanted to structure games into her day now I'm really excited to tell you what some programs and communities just like yours are doing to use video games for mental health and suicide prevention stack up is a non-profit organization that serves 10,000 veterans nationwide each year through its discord server discord is a chat program that was originally designed for online gamers they saw a need for mental health support for their members so they developed the stack up overwatch program or stop stop provides free anonymous private chat with volunteers who are trained in crisis intervention they connect with those in need to assess suicide risk discuss problems brainstorm solutions and share resources stop served 60 people in 2018 and is on target to serve 90 in 2019 I'm happy to say that I'm currently collaborating with them on a grant with the Centers for Disease Control to develop methods for evaluating all of the stack up programs now the second one operation heal was an online educational conference held last year for the veterans affairs community we had many researchers clinicians veterans and suicide prevention specialists sharing stories of what worked for them where the research was and what was still needed we had clinicians talking about how they use gaming and clinical practice how video games were useful in mental health recovery and first person accounts of how gaming saved lives as well as perspectives on social media and suicide prevention I think I'm running a little slow so let's see no you're fine just keep on okay we also had grassroots efforts in the online gaming community and this online setting was a great way for clinicians and veterans to share knowledge and to learn from each other it leveled the playing field like we talked about earlier and tomorrow is another presentation that I'm really excited about the American Association of Suicidology is a panel tomorrow Saturday in Denver suicide prevention in video gaming communities sorry one second I helped organize this panel with some suicide prevention specialists and we'll have representatives from organization that promote mental health in gaming and gamers including StackUp they'll talk about how their organizations use or promote games for mental health and crisis intervention please consider tuning in the panel will be live streamed on twitch.tv at the link there all of this good stuff I'm telling you about video games is not the whole story we currently have two proposed disorders related to excessive use of video games when I started researching this I was convinced that the benefits of games outweighed the problems I've since learned that a lot of the research on disorder or problematic gaming is not great but I've also learned that all over the world a small percentage of people who game or use social media have true problems related to not being able to control their use as Tony mentioned in his presentation earlier the origins of these diagnoses are in boot camps in China parents saw their children neglecting responsibilities in school in favor of online games so some enterprising individuals capitalized on that by coming up with unique but untested treatments well meaning psychiatrists saw this and said we need to define a disorder so that only the most severe clinical cases would be seen as needing treatment and they would get actual medical care the problem is that a lot of the concern about excessive playing gets labeled with terms like dopamine hijacking and there's a thought that games are so inherently pleasurable that everything else becomes meaningless this has been tested again and again with studies of brain imaging but again there's only one small problem many activities are inherently rewarding but I've never seen a study where other pleasurable activities are compared to video gaming with this brain imaging so who knows how the brain of someone on games compares to that of someone who's listening to music that they love another problem is measurement all of these online spaces and activities are blending together there's also the problem of researchers many of whom aren't really familiar with the activities that they study so a lot of the evidence about what is called gaming disorder is actually from studies that ask questions about internet addiction and of course that makes it hard to tell what is what it's not just the amount of play social context and people's overall well-being is really important for the outcomes of playing a lot so instead of thinking of problematic gaming as a continuum based on time it's better to see it as linked to groups of people and their characteristics in one of our studies we found that groups of adolescent gamers who played for four or more hours a day the only ones who didn't test higher in depression measure depression symptoms were boys who also communicated a lot online and had a lot of online friends so rather than being about just the person or just the video game it was a combination of person factors and types of communication that mattered and this is really important from a statistics perspective because if you give someone a survey and then you score them from one to ten you're mixing people who really have problems as a result of their heavy gaming with those who play a lot of games but don't have problems who are showing healthy engagement and when you mix people like that you can wash out any associations between real problematic gaming and the things that you're trying to look at that could be results or could be things that predict it another important thing to consider is that as we found in our systematic review of studies that took place over time people move in and out of states of excessive or problematic use and about half the time it seems to resolve within a year or two this doesn't mean it's nothing a year or two in a child's life is a big deal a year or two of problematic gaming during troubled marriage could mean divorce and another troubling thing is that the mechanics of games and other online spaces are changing more and more we're seeing gambling mechanisms in games or other persuasive techniques they're very carefully designed to encourage people to continue to play and to bring their friends with them so in the debate about whether we're ready for a specific gaming disorder diagnosis the controversy in the scientific field has polarized and devolved into name calling over the last few years the other thing to keep in mind is that excessive use is subject to self control a lot of researchers are looking at that in one of our quotes from the study of veterans I mentioned it in the panel this veteran said that I have a final two weeks from yesterday I need to focus on that it separates the game from real life it being subscribing to the game for a month in order to not feel like you have to log in because you can get resources just from paying to subscribe so he said it separates the game from real life and says there's no distractions when I'm studying I'm not looking down at the task bar going let me see if anybody needs me that was, sorry you don't need the ID number 7 mail Tony Van Royne who presented earlier and I have been opposed to a disorder for a while but we're starting to change our minds based on what we're hearing about the clinical need these reports aren't out in the scientific literature yet so it's a little hard to judge but I still don't think a diagnosis limited to video games makes sense because of this thing right here, Harmony the sex robot she is the android head for a sex doll body and she currently costs about $8,000 just for the head my concern is what happens when Harmony is affordable to more people if we decided to target games for a disorder because we think games are the only type of technology that people are really addicted to how will the people who can't stay away from Harmony get the help they need there are a lot of challenges to doing this research first if we're going to use AI to try to track in-game behavior or to analyze chat we're going to run into the big data issue this is a growing field but what we know so far is that people from different fields will need to work together to find the best ways to analyze these data we also have a problem with how we collect all the evidence so in some fields there's still a really negative attitude so if you're a researcher looking to collect all the papers on games you have to make sure that you include the euphemisms for games like digital interactive rehabilitation technology or virtual reality we also have to figure out how to take small clinical trials out into the scale of the internet what do we do to translate the 30 people who play tetris or bejeweled into 10,000 people this is going to require a lot of staffing and a lot of money so researchers and clinicians will have to figure out ways to partner with industry to do that like this promotion for starbucks within kumango conflict of interest is of course a big problem in health research we know that from the tobacco industry big pharma etc and ways around it include disclosure of financial relationships but that might not be enough there's also unintended consequences of trying to use games for good and these usually aren't measured in studies but they need to be addiction is only one potential problem we should also be worried about things like privacy violations persuasive advertising in games and gambling mechanisms in games which are starting to be subject to regulatory control as they sneak in there here's my vision of meeting people where they're at for me it was always world of warcraft sometimes people in the game need help we can recruit world of warcraft players who have depression for a study then use machine learning on their publicly available data to search for patterns we can combine the machine learning with questionnaires that are delivered in the game that look like the games interface so people don't get their immersion broken or too broken this will help us identify when people need help then to close the circle we can deliver the help they need where they're at in this case standing on a tower in the capital city storm wind my character shown here is not a healer but with training she and I could provide good peer support I'd like to leave you with this thought the new norm of a hyper connected reality is already being replaced by mobile augmented reality this allows people to always be connected but also to integrate these online environments into the real world and it might help people get out into public to meet people socialize and get physical activity but those benefits won't be equally accessible to all these fascinating new games will be everywhere and it might be hard for people to learn to self-regulate and install the novelty and as technologies continue to evolve we'll also have to evolve new methods to answer these complex public health questions about how we can take advantage of the benefits of video games while minimizing potential problems I'd just like to take a minute to thank all of these people who've made it possible for me to do this research I consider myself very very fortunate and a special thanks to Gentle Heron for the opportunity to talk to you all here today please click the box here to get a note card of my references list hopefully we still have time for questions we do we have time for a couple of really quick questions if there are people from the audience and Luke has one she says regarding the point games are tools for re-focusing the mind in veterans with PTSD or suicide ideation this involves the distraction method it works while the game is on but unfortunately you cannot play a game 24-7 but you found only long term persisting benefit from such short-term game therapy I think one of the things I saw with this was actually more with the women veterans that we interviewed they seem to have more of a sense of when I do this in the game it gives me some confidence that I can do it in real life so the idea would be that even though I may not be able to access the tools if I can do something to distract myself then I have a little bit of control of ability so therefore maybe it will take some time but I can learn how to do this outside of games so it's not the game that they're learning it's the distraction technique they're learning yeah it's a coping technique exactly when nothing else works but over time you're internalizing I can use a distraction coping technique yeah I like that idea the female male difference was really impressive okay I've got a question you talked about hearing two people talking about the idle hands metaphor what are some other metaphors that people have employed to describe their use of games oh boy that's a good question I think I was just so struck by the idle hands one that that really became that was my main take away I'm sure there were others but I can't think of them off the top of my head okay do you want to pose that as a question I wasn't sure how you were closing that I'm wondering if you mean what are the implications of this for people who are making games is that the question well I'll assume that that is for now because that's a really good question and I'll say that there are two well there are three main things really one would be to use ethical game design principles to ensure that you're not building in mechanisms that are so persuasive that they make it really hard for people to stop gaming so build in those natural breaks or other ways that people can learn to self-regulate the other thing would be to consider how to take advantage of the social benefits of games and some platforms do this for a financial motivation but there are developers who are interested in developing these beautiful virtual worlds as social spaces so that's what we want obviously and the other thing would be about data for this framework to work we need access to data and some platforms allow some access to data but it would be nice for developers to be willing to work with researchers so that we can perform studies in our areas of expertise that might be useful for the developers but they would also be useful for us as public health researchers to try to develop these kinds of interventions and I really hate to once again cut our discussion short but we're going to have to give our next presenter a little bit of time new research, Michelle, has many applications you really give us a lot to think about I'm going to definitely encourage the audience to click the giver box at the base of the podium there to get the note card of your references and I want to align the audience that after this break Holly is going to explain how his organization trains mental health professionals to help veterans and their families cope with PTSD using Second Life as the training venue and at the end of his session after the Q&A with the audience we'll get to go see two Second Life sites that he's built to help mental health providers use the most recent research supported strategies to provide mental health support so please take a break audience thank our presenters so far and come back at the top of the hour for another presentation thank you Michelle