21 1 GENERAL INTRODUCTION anxiety (Boettcher et al., 2013). Thus, expectations for improvement influence intervention outcomes as well as engagement with conventional programs. It is unknown whether similar processes may be at hand in applied games, but the findings of the two earlier mentioned RCTs performed by our lab suggest so. More specifically, expectations for improvement may explain the equal improvements in anxiety that were found for both the intervention and control games (Scholten et al., 2016; Schoneveld et al., 2016). In our RCTs, we made sure that youth’s expectations for both the applied and (casual) control game were equal, prior to the random assignment. However, in doing so, youth in both groups had similar expectations of effective anxiety reduction, which might have resulted in the equal improvements we observed in both the intervention and control group. Therefore, it is important to examine the effect of expectations on engagement and positive intervention outcomes in applied games, such that we understand to what extent specific therapeutic techniques and nonspecific factors each explain positive outcomes and whether enhancing expectations prior to gameplay would be fruitful. Motivation to change may be a second variable that could explain the equal improvements in anxiety we found in our RCTs , and a nonspecific factor that generally may be relevant to take into account in research on applied games. Motivation to change refers to an individual’s readiness and willingness to change the symptoms or challenges they are facing (Prochaska & DiClemente, 1982). It has been recognised as one of the key predictors of (conventional) treatment outcomes, as well as a significant factor influencing variables associated with engagement (e.g., treatment engagement, adherence, and dropout; Brogan et al., 1999; Derisley & Reynolds, 2000; Lewis et al., 2012; Lewis et al., 2009; Norcross et al., 2011; Taylor et al., 2012). Individuals lacking motivation or not yet prepared to address their symptoms are less likely to show improvement post-treatment, and tend to invest less time or engage less actively in the treatment process. Although games are naturally appealing and considered intrinsically motivating and engaging (e.g., Granic et al., 2014), based on previous research we expect that individuals’ motivation to change may still influence actual engagement and their perseverance in the face of failure, and subsequent mental health improvements. Therefore, it is important to examine motivation to change in applied games. Symptom severity may be another important nonspecific factor to consider. Although previous research on conventional programs has not yielded conclusive results, there is research suggesting that higher symptom severity or symptoms at baseline are related to more professional help-seeking and greater symptom decreases after intervention (Merikangas et al., 2011; M.
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