and hospitalization—and most important, better survival outcomes.
Families and patients know this, but young people miss doses anyway, for many different reasons. They can’t stand the side effects, such as nausea and fatigue. They get busy with school or sports as they start to feel better, making it harder to follow a strict medication routine. Or after years of treatment, they subconsciously rebel and forget to take the drugs, because they are just “sick of being sick.”
Re-Mission was designed to prevent these lapses, by helping young patients feel more optimistic and motivated to take their medications. As senior HopeLab researcher and UCLA professor of medicine Steve Cole told me, “Thirty percent of kids miss twenty percent of doses or more. Those kids have twice the risk of having a rebound of the leukemia. This is a completely avoidable risk. We have to somehow get across the message: No matter how bad the disease is, you are fundamentally in control of your health, and no one can save your life if you don’t do your part.”
Cole and his collaborators hoped that patients would become more committed to their treatment plans if they learned more about chemotherapy in the empowering context of a video game. These lessons were integrated right into the game play. For example, when the virtual patient in the game skips a chemotherapy dose, Roxxi’s chemo-blaster weapon starts to malfunction, misfiring every third shot. Skip another chemotherapy dose, and more virtual cancer cells survive each blast. Skip again, and cancer cells become drug-resistant, further increasing the challenge of each level.
So did it work? Yes, overwhelmingly. In a clinical trial, patients who played Re-Mission for as little as two hours had greater medication adherence for three months.1
Electronic pill-cap monitors showed that the game players took 16 percent more antibiotic doses over a three-month period than nonplayers. This means the game effectively eliminated a whopping half of the typically missed doses. And when patients’ blood was drawn and tested, Re-Mission players had 41 percent higher doses of the cancer-fighting medication in their bodies. They were significantly more successful in keeping up with treatment—and therefore more likely to stay in remission.2 (The trial was conducted with 375 patients, aged 13 to 29, at 34 medical centers across the United States.)
Interestingly, a full quarter of the study participants reported that they rarely played video games before the trial. Another third had previously played just one or two hours per week. In other words, these were not hard-core gamers who were benefiting from the game. The game worked equally well for novice or infrequent game players as it did for lifelong players—and it is continuing to work for patients worldwide. As a result of this successful clinical trial, Re-Mission has been distributed to more than 250,000 cancer patients. And recently HopeLab released six follow-up cancer-fighting games online, including Stem Cell Defender and Nanobot’s Revenge. (They are free to play at www.re-mission2.org.)
HopeLab’s games are an incredible, potentially life-saving resource. But even if you aren’t battling cancer, the Re-Mission research offers a powerful, life-changing insight: motivation alone is far less important to success and willpower than you think.
Before the cancer patients played Re-Mission, they were already fighting for their lives—presumably a highly motivating state. This was not a group that simply needed more motivation. They had it in spades, yet they nevertheless regularly failed to do the things they knew could dramatically improve their chances for a cure.
Somehow the video game Re-Mission intervened in a way that converted mere motivation into a much more powerful psychological resource. But what is that resource? And how did the game create it so quickly?
This is exactly what the HopeLab team was wondering after they saw the success from their first clinical trial. Originally, they had hypothesized that thirty hours of play would be necessary to make a positive impact on medication adherence. They were amazed when just two hours made such a significant difference. And they had expected players to need continual reinforcement and reminders from the video game every day in order to keep up their behavior change. Yet it turned out that playing the game just once was enough. It was truly a surprising result. What could explain such long-term, real-life behavioral changes after such a short time of virtual play?
The key to solving this puzzle was found in another set of data that the researchers collected during the clinical trial. They weren’t just monitoring medication adherence. They also tracked psychological changes during the trial. Players and nonplayers reported the same levels of motivation, stress, cancer symptoms, and physical side effects, but the game players differed remarkably in one area. They reported feeling significantly more powerful, optimistic, and able to positively impact their own health than nonplayers.
Psychologists call this state of mind self-efficacy. It’s the belief that you, yourself, can effect positive change in your own life.
Self-efficacy is not the same thing as self-esteem, which is a more general positive feeling of self-worth. Self-efficacy means having confidence in the concrete skills and abilities required to solve specific problems or achieve particular goals. It is usually context-specific: you might have high self-efficacy at work but low self-efficacy about public speaking or losing weight.
Self-efficacy is the crucial difference between having lots of motivation but failing to follow through, and successfully converting motivation into consistent and effective action. With high self-efficacy, you are more likely to take actions that help you reach your goals, even if those actions are difficult or painful. You also engage with difficult problems longer, without giving up. But with low self-efficacy, no matter how motivated you are, you’re less likely to take positive action—because you lack belief in your ability to make a difference in your own life.
So where did the Re-Mission players’ new self-efficacy come from? Well, all games are intentionally designed to increase players’ feelings of competence, power, and skillful ability over time—in other words, to build up their self-efficacy. Like all video games, Re-Mission challenges players to achieve a difficult goal: navigating through a complex, 3-D space and destroying all the virtual cancer cells before time runs out. This goal requires skill, practice, and effort. Players of Re-Mission, like players of all games, are typically unsuccessful at first. But quickly, with repeated effort and as they learn how the game works, they start to improve their skills and strategies. Eventually they master a few challenges. And because it’s a video game, it gets harder. The challenges get more difficult and complex with each new level. This constantly escalating challenge requires a willingness from players to keep trying, even when they fail. It instills a belief that if they keep practicing and learning, if they put in the hard work, they will eventually be able to achieve more difficult goals.
This is the classic path to increased self-efficacy: accept a goal, make an effort, get feedback on that effort, improve a concrete skill, keep trying, and eventually succeed. You don’t need a game to set off on this path. But because it is the very nature of games to challenge and improve our abilities, they are an incredibly reliable and efficient way to get there.
And here’s the good news: once you have a feeling of self-efficacy about a particular problem, it tends to persist. It’s a lasting mindset shift, permanently changing what you believe you are capable of and what goals you believe you can realistically achieve. And this is exactly why Re-Mission worked so well. The game created a new source of self-efficacy for young patients, in a situation where it is easy to otherwise feel powerless or overwhelmed. Instead of seeing chemotherapy as a negative experience they were forced to undergo, they came to see it as a powerful weapon they were fully in control of. They understood exactly how it worked, and they weren’t afraid to use it!
This shift in mindset alone—from powerless to
