State of Care: Participatory Policymaking using Serious Games
Creators: name: Watson, Chloe
name: Trust, The Wellcome
Publisher: name: F1000 Research Limited
Year: 2024

description: <i>This report sets out the findings from one of four projects commissioned by Wellcome Policy Lab to pilot creative approaches to policy development. In this project, Thumbi Labs and the Centre for Mental Health Law &amp; Policy have piloted the use of a storytelling game and simulation to inform policy discussions on local governance and mental health in India.  </i><br>
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<b>Report content</b><br>
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<b>Acknowledgements</b><br>
We would like to express our gratitude to the Department of Health and Family Welfare, and the Department of Rural Development, Government of Chhattisgarh, India for extending their support towards this project. We extend our gratitude to R Prasanna (Secretary, Department of Higher Education, Chhattisgarh), Dr. Mahendra Singh (Director, National Mental Health Programme) and Dr. Sumi Jain (Technical Consultant, Non-Communicable Diseases) for their support in implementing the pilot.<br>
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We would like to thank the district nodal officers of Health and Panchayat Departments in Dhamtari and Rajnandgaon districts, who helped us identify participants for the various workshops that were a part of this pilot.<br>
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This pilot would not be possible without the meaningful participation of our various community stakeholders. We owe our sincere thanks to our participants with lived experience, their caregivers, representatives from the community-based organizations who shared their insightful stories with us, as well as the panchayat representatives who were open to engaging with the digital simulation game and solutioning workshop.<br>
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We would like to thank Solidarity Foundation for their support in game tests of the storytelling game, and external participants for the participation in the game test for the digital simulation game. We would also like to thank Tridindia and Dilip Kandukuri for their support in translations.<br>
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We are grateful to the team at Wellcome Policy Lab: Chloe Watson, Tom Harrison and Martin Smith for giving us this opportunity to experiment with policy tools in our unique context and for their support at every step of the process.<br>
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The report was developed by Thumbi Labs and the Centre for Mental Health Law &amp; Policy, Indian Law Society and is supported by the Wellcome Trust Policy Lab.<br>
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<b>Executive Summary</b><br>
Conventionally, policy processes rely upon formal and technical approaches to engage with actors who have technical expertise and proximity to political centres. Most often, these processes exclude direct engagement with the lived experiences of individuals and communities who are impacted by policy decisions. Further, the form and structure of such processes do not create space for the diverse ways in which community members may process, articulate and express their experiences on policy issues which have implications on their lives and wellbeing. In the context of mental health, community members with lived experiences of mental health challenges are far removed from these processes due to barriers in mechanisms to access and engage with policy planning and implementation.<br>
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Mediums like storytelling, serious games and collaborative workshops offer innovative avenues to humanise policy processes by making them interactive and experiential. Such tools also create space to facilitate dialogue on insights and experiences in a manner which is accessible and relatable for community members in their cultural contexts.<br>
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To leverage the potential of storytelling, serious games and collaborative workshops, we developed three tools- a storytelling game, a digital simulation game and a solutioning tool incorporating concepts of storytelling, role play and collaborative planning. Our pilot initiative implemented these tools in the districts of Rajnandgaon and Dhamtari, Chhattisgarh, India involving people with lived experiences (PLEs) of mental health conditions, caregivers, community-based organisations (CBOs) and elected panchayat (local village councils) members. Through the pilot workshops, we adapted and iterated the tools to align them with the contextual requirements and participants’ needs.<br>
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The tools were evaluated through observations, group discussions and semi-structured interviews along with thematic analysis of the data generated through various stages of the workshop. The inquiries during these stages focused on understanding participant engagement, challenges encountered with the tools and its potential to develop policy insights.<br>
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Through the pilot we were able to demonstrate the ability of these tools vis-a-vis conventional approaches, to make the policy process more accessible to the community-based stakeholders. Through the storytelling game we derived narrative evidence from the experiences of the community, providing for nuanced policy insights. Through the digital simulation game and solutioning tool, we engaged panchayat members in identifying challenges faced by the community and articulating pathways to address them.<br>
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<b>Chapter 1: Introduction</b><br>
It is increasingly recognised that policy development should involve meaningful engagement with community stakeholders such as people with lived experience of mental health problems (PLEs). Historically, mental health policymaking has been driven through a top-down approach using conventional policy meetings and consultations. These processes disadvantage or exclude communitybased stakeholders such as marginalised communities and PLEs. Engaging community-based stakeholders is imperative to generate insights into how policy can support access to equitable, community-based and culturally acceptable mental healthcare. With support from Wellcome Policy Lab, this project aimed to develop and pilot a new participatory approach comprising serious games for participatory policymaking with a focus on mental health policy in Chhattisgarh, India.<br>
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<b>The need for greater participation in mental health policy in India</b><br>
In 2017, it was reported that 197 million people were living with a mental illness in the country[1] of whom 70% to 92% didn’t have access to any form of care[2]. India’s law and policy framework adopts an inclusive, integrated, participatory, rights-based, and evidence-driven approach to mental healthcare. The National Mental Health Policy, 2014, provides a holistic and intersectoral roadmap for mental healthcare while recognising the need for addressing the social determinants of mental health[3]. The Mental Healthcare Act, 2017, recognises the right of every individual to access mental healthcare from state run or funded services which are affordable, available, accessible and culturally acceptable[4]. <br>
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Further, the flagship District Mental Health Programme, 1982 (DMHP), integrates mental health services into primary care especially in rural areas across 738 districts in India[5].<br>
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Globally, it is found to be imperative to engage community stakeholders such as PLEs[6], civil society[7] and local governments in mental health policy formulation and implementation. While grassroot policy processes under the 73rd and 74th Amendment of the Indian Constitution empower local self-governance councils or panchayats to facilitate development, they have not addressed mental health as a governance issue[8], [9] and community stakeholders continue to be excluded from the policy processes[10]. Therefore, there is a need for participatory tools that include community-based stakeholders in policymaking processes that account for the diversity of literacy, languages, and social contexts in India.<br>
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<b>Games as a participatory tool for policy engagement</b><br>
Games are an effective medium to engage community stakeholders in sharing knowledge and insights through interactive and engaging processes. They also provide a unique opportunity for policymakers and officials to experience how the system works on the ground and identify pathways to address challenges with the resources at their disposal. Games are relatable and accessible to people from varying literacies, languages and contexts. They hold potential for a bottom-up mechanism for policy formulation and help PLEs caregivers and marginalised communities move upward in what Sherry Arnstein defines as the “ladder of participation”[11]. Thus, communities have an equal opportunity to be consulted regarding their rights and entitlements before on-ground officials, local government and policymakers develop policy interventions that affect them.<br>
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<b>About this report</b>

 In Chapter 2, we summarise the objectives of the pilot.
 In Chapter 3, we describe the process and methods for game design
 In Chapter 4, we describe the process of testing the tools with community stakeholders.
 Chapter 5, highlights the policy insights gained from the pilot.
 The report concludes with Chapter 6, where we provide a synthesis of our learnings and reflections while developing and piloting these tools with guidance for how others can make use of these methods in their work.

<b>Chapter 2: Approach to the pilot</b><br>
In this pilot, we developed and tested a participatory approach to community level policymaking that consisted of three interactive gaming tools- 1) storytelling game 2) digital simulation game and 3) solutioning tool. These tools were piloted in Rajnandgaon and Dhamtari – two districts of Chhattisgarh, India. The pilot focused on community stakeholders comprising 1) PLEs, caregivers and communitybased organisations (CBOs) working on social determinants of mental health and 2) elected panchayat members responsible for local governance in villages. These tools aimed to empower communities who are structurally and historically excluded from mental health policy processes to meaningfully participate and contribute to improve care in their communities. The detailed approach we adopted during this pilot is illustrated in Figure 1.<br>
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<b>Figure 1:</b>


 <b>Step One - Storytelling game:</b> People with lived experience of mental health problems, caregivers and community organizations share their stories of accessing mental health care.
 <b>Step Two - Digital Simulation game: </b>Composite stories are created and fed into a digital simulation game for panchayat members to experience the challenges and supports available in the community.
 <b>Step Three - Solutioning tool: </b>Group visioning and solutioning exercise among panchayat members to identify pathways for policy interventions to improve mental health care for their community members.

Through the pilot, we aimed to assess:


 The experiences of piloting the tools in the two districts with different groups
 Whether the tools were inclusive of and accessible to diverse community stakeholders 
 Whether the tools are able to capture qualitative and narrative policy insights across diverse participants from both districts
 Whether the tools provide novel policy insights and solutions compared to traditional approaches
 Whether the adaptations and modifications required in the tools met their objectives.

<b>Chapter 3: Developing the tools<br>
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<i>Methodology we used to develop games / tools</i></b><br>
We use a five-step iterative methodology to ideate, design, implement and refine games/ tools. The methodology centres stakeholders and employs participatory design that closely meets their needs. The process was guided by the Centre for Mental Health Law &amp; Policy’s (CMHLP) experience and expertise working in mental health in rural communities in India. The tool design was achieved by iteration through multiple workshops to accommodate the needs of people using the tools. The interdisciplinary game design methodology is illustrated in Figure 2 [see PDF report for figure]<br>
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<b>Stages of process (from Figure 2)</b><br>
<b>A. Problem formulation</b><br>
involved identifying the problem that the tool aims to address. We carried out an initial scoping workshop to define the boundaries of each tool, potential elements and the preliminary set of challenges. Subsequently we identified a preliminary set of stakeholders and relevant policy provisions that impact the problem. Finally, we defined the problem as - lack of availability and access to mental health care and support in the community.<br>
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<b>B. Conceptual modelling</b><br>
entailed designing a model of the local context in which the tools would be located. This included the different actors, their resources and constraints, and the relationships between them. We mapped the local mental health system within the district to identify the various stakeholders that individuals have access to for mental heath support. This included formal supports through local health centres, community health workers, non-profits, and institutional supports (hospitals, panchayats, schools, law enforcement etc.). Additionally, we identified informal actors that included family members, peers, neighbours, community leaders and faith healers who play an integral role in facilitating access to mental health.<br>
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<b>C. Game design</b><br>
integrated design elements with the conceptual model. We decided the formal elements of the game, which included objectives in the game, roles, constraints, resources, conflicts and boundaries. At this stage, we also designed and tested prototypes, which entailed rigorous testing and validation through play tests with intended users along with subject matter experts (CMHLP).<br>
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<b>D. Game as an Integrated Intervention</b><br>
implies that games are not a standalone tool and must be embedded in structural and institutional processes to ensure sustainability of the desired objective of the game. In later sections, we discuss how the tools were piloted an integrated intervention in the pilot, and how we envision embedding them in policy processes in the future.<br>
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<b>E. Outcomes/Recommendations</b><br>
nclude lessons on the value of the tools and guidance for other stakeholders to adopt these methods and incorporate learnings in their work. In our pilot, it included a dissemination workshop with district officials of the District Mental Health Programme to showcase the tools, reflect and discuss the potential of embedding this method as part of policy processes.<br>
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While the methodology appears to have distinct steps, there are significant overlaps and iterations between each step. In the following sections, we briefly take you through the storytelling game, digital simulation game and solutioning tool along with the rationale for integrating them during the pilot.<br>
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<b>Storytelling game</b><br>
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<i><b>Objective</b></i><br>
The objective of the storytelling game is to enable people with lived experiences (PLEs), caregivers and CBOs to articulate their experiences of accessing mental healthcare. These stories act as narrative evidence of policy gaps in the current mental health system.<br>
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<i><b>Why are stories an important tool for policy development?</b></i><br>
Stories are a rich source of qualitative narratives providing insights into people’s experiences, preferences and needs. The act of sharing stories establishes a shared understanding and connection between the listener and storyteller, unearthing similarities in challenges faced and support received through an engaging medium. Storytelling captures the subjective and nuanced experiences of individuals as members of a community that may not be captured through traditional data collection methods such as surveys or structured interviews.<br>
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Further, this method sheds light on how policies are experienced by individuals and communities; functioning of policy mechanisms on the ground; and actual impact (versus intended impact) of policies on communities.<br>
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In this regard, stories from PLEs, caregivers, and CBOs can help us gain in-depth and nuanced experiences of accessing institutional and social support systems which can inform future policy decisions. Storytelling through games is engaging and economical providing a semi-structured, non-confrontational, and congenial environment which encourages participants to share and listen to multiple perspectives in a short span of time. The individual and social learnings that emerge from such games can be transferred to the real world through formal and informal processes. In the storytelling game, complex information is presented through relatable and engaging methods, ensuring that it can be played with individuals with different levels of literacy. The game acts as a data collection mechanism to collect narrative evidence and qualitative insights.<br>
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<b>Key elements of the storytelling game</b><br>
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<i><b>Pre-existing model</b></i><br>
The storytelling game for this pilot was a modification of an existing tool called Ondu Kathe Keli (OKK)[12]. OKK was developed to capture people’s experience of policy implementation.<br>
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<i><b>Players and duration</b></i><br>
The game accommodates between 10 and 40 players in a single session and requires between 90 and 120 minutes for gameplay.<br>
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<i><b>Objective</b></i><br>
The objective of the game is to provide a semi-structured, safe sharing environment for participants to narrate their stories and experiences of accessing mental healthcare in the community.<br>
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<i><b>Ice-breaker and context setting</b></i><br>
The session starts with an icebreaker activity to build rapport between the participants and the facilitators. This is followed by a brief context setting on what is mental health.<br>
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<i><b>Consent, recording and analysis</b></i><br>
With the informed consent of participants, we recorded the stories during the session. The stories were later transcribed, analysed and grouped into challengecategories. These challenges were drawn upon for developing the digital simulation game.<br>
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<i><b>Gameplay</b></i><br>
Each storytelling game is conducted with a specific group of participants, to ensure conversations are focused. In the game, participants play the role of either storytellers or listeners. The game setup consists of booths which represent a specific actor/ institution. In the pilot, the four booths were: 1) Family, peers and neighbours; 2) Health facilities; 3) Panchayats and 4) Non-profit organisations. The number of listeners in the game is equal to the number of booths.<br>
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The listeners are stationed at different booths, while the storytellers visit booths to share their stories. The storyteller shares stories from their experience about the actor/institution represented in the booth. The listener is free to ask clarifying questions if required for them to understand the stories better. At each booth, listeners are provided with two sets of different coloured blocks representing either a challenge or a support.<br>
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After listening to the story, the storyteller is presented a block that signifies if the story represents either a challenge or support from the perspective of the listener. The storyteller then deposits the block into the jar kept at the centre of the room. During the game, after a pre-decided time interval, the listener and storyteller can exchange their roles. The game continues until the jar is full.<br>
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Once the jar is full, the game stops, and this is followed by the debrief, where everybody sits in a circle, and the listeners share a summary of the stories they heard. This is followed by a structured discussion on the challenges and support available in the communities.<br>
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<b>Digital Simulation Game &amp; Solutioning Tool</b><br>
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<i><b>Objective</b></i><br>
The objective of the digital simulation game and solutioning tool was to 1) to provide local policymakers and government officials with an immersive experience of the journeys of individuals (with mental health problems) navigating the mental health system to access services and 2) to nudge panchayat members in articulating their role and identifying pathways to address challenges highlighted in the digital simulation game through existing institutional policy mechanisms available to them.<br>
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<i><b>Why are simulations an important tool for policy development?</b></i><br>
Simulations are immersive techniques that emulate real-life scenarios with the intention to understand the impact of certain decisions, choices or events in specific situations. Simulation games are a powerful medium that allow players to step into someone else’s shoes, navigate through their journeys, confront the challenges they face and encounter the resources, systems and supports available to them. These journeys modelled on real-life scenarios, leverage the role play mechanism to question biases and reduce the distance between the policymaker and the individual or community. This perspective enables participants to temporarily suspend their frame of reference as local government officials and instead identify policy gaps and solutions from the perspective of PLEs rather than their official roles.<br>
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<i><b>Why a solutioning tool?</b></i><br>
The transition from the digital simulation game to a facilitated solutioning workshop was intentional to encourage creative and speculative thinking among participants. Semistructured group activities during a workshop encourage dialogue and collective solutioning among participants to reflect, reframe and derive policy insights on complex policy problems and potential solutions. To transition from the digital simulation game to the solutioning tool, we asked panchayat members to map out various challenges they experienced as a character in the game. This activity allowed for reflection on the game and helped make the challenges explicit for the participants which they addressed in the rest of the session.<br>
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<b>Key elements of the digital simulation game and solutioning tool</b><br>
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<i><b>Players and duration</b></i><br>
The digital simulation game along with the solutioning workshop accommodates a minimum of 6 and maximum of 20 players in a single session and requires 4 hours for gameplay and solutioning. In the pilot, the session was split into 2 parts - 1.5 hours for the digital simulation game and 2.5 hours for the solutioning tool in a workshop format.<br>
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<i><b>Introduction and context setting</b></i><br>
The session starts with an introduction of the players and facilitators. This is followed by a brief context setting of what constitutes mental health care.<br>
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<i><b>Objective</b></i><br>
The objective of the digital simulation game was to help panchayat members understand the challenges faced by communities in accessing quality mental health care and support. This was followed by a solutioning workshop where the aim was to help the participants reflect on their roles and envision pathways to improve mental health care access in their communities.<br>
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<i><b>Gameplay</b></i><br>
The digital simulation game consists of two stories meant to engage the panchayat members to understand the challenges from the perspective of people accessing the mental healthcare. These stories were developed from the analysis of the stories collected from the storytelling game.<br>
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The panchayat members play as the central character in each story and try to improve the situation the central character is facing. In the first story the central character is a young adult who is facing trouble with their education and has taken to substance abuse, while in the second story the central character is a person, whose sister is coping with a severe mental health illness and domestic abuse. As a player the panchayat members try to improve the characters condition through various choices available to them and understand the consequences of their choices. The game begins with players exploring the first story on a laptop which takes approximately 10-15 minutes.<br>
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Once they finish the first story the players come together in groups of 4 to engage in the first activity of the solutioning workshop – problem articulation – by filling in a problem articulation activity sheet. In this activity, the players list down challenges and the support they experienced as the character in the first story by different actor groups – family, friends, community members, government and non-governmental institutions. The players return to the laptop to play the second story. Once they have played the second story, the players regroup to populate the problem articulation activity sheet.<br>
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The second part of the session focuses on the solutioning workshop. On the problem formulation sheet, the players mark challenges where the panchayat can play a role. This is followed by the second activity sheet – Newspaper of the Future – where the participants shortlist challenges marked in the previous sheet and envision a newspaper headline which describes how the challenge has been tackled in the future.<br>
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The solutioning workshop ends with the last activity wherein players identify pathways and interventions necessary for the envisioned future to become possible. By listing down challenges, understanding their roles, and identifying pathways, the solutioning workshop brings the players together to participate in effective solution building.<br>
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<b>Chapter 4: Tool testing process</b><br>
In this chapter we discuss how the three tools were tested during the pilot. Table 1 provides a summary of the workshops conducted in the districts of Rajnandgaon and Dhamtari in Chhattisgarh. Detailed information on the various workshops is presented in Annex 1.<br>
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[see PDF report for details of Table 1]<br>
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Before the pilot, prototypes of the tools were tested with various groups to assess game mechanics and participant engagement. The storytelling game was tested in Bangalore, India, with members of marginalised communities. The digital simulation game and solutioning tool were tested online with individuals in the social development sector, not necessarily linked to mental health. Following these initial tests, the tools were piloted in Chhattisgarh’s districts.<br>
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Throughout the pilots, the tools underwent further iterations based on observations and feedback from participants. To assess whether the tools met their objectives, we implemented an evaluation process across multiple workshops. Table 2 outlines the evaluation parameters, the corresponding methods utilised and the stages at which evaluations were conducted. These parameters facilitated the assessment of various versions of the tools which informed the development of iterations.<br>
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[see PDF report for details of Table 2]<br>
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<b>Chapter 5: Policy insights from the pilot</b><br>
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Across all the workshops, we gained diverse perspectives from participants on

 Mental health issues
 Challenges in accessing care and support; and
 Pathways and interventions to address the challenges.

We present below the insights gained from the participants post engagement with the storytelling game and digital simulation game and solutioning workshop.<br>
<br>
<b>Storytelling game</b><br>
By analysing the many stories that were captured in the storytelling workshops, we were able to derive policy insights which policymakers could engage with at different levels. In terms of the type of stories, there were stories that demonstrated challenges faced by people, and various support mechanisms that were available to them. Stories of challenges were predominant in comparison to stories of support available to people. The challenges encompassed barriers in accessing mental healthcare from formal systems, the impact of poverty, stigma, role of families, domestic violence, substance use, unemployment, income inequality and lack of adequate facilities/services to ensure timely and affordable care. The summary of various challenges and their frequency are presented in the Figure 6 and Figure 7.<br>
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[see PDF report for details of Figure 6 and Figure 7]<br>
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<b>Digital simulation game and solutioning tool</b><br>
Through the simulation game, the panchayat officials demonstrated that they understood the multifaceted and layered nature of accessing mental health care, where social and economic factors had a significant bearing on health. They recognised challenges that originate among family, friends and wider community networks (such as neighbours) that have an impact on mental health. The members gained insight on the distress stemming from academic stress, domestic violence and livelihood factors which can act as a barrier to providing adequate support to the person experiencing distress. They also articulated their potential role in addressing the various challenges highlighted. Figure 8 provides a summary of the various actors amongst whom panchayat officials recognized challenges and opportunities for intervention.<br>
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[see PDF report for details of Figure 8]<br>
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The panchayat members identified their role in establishing connections with hospitals and at the family level. Additionally, they emphasized their potential role in ensuring treatment services are provided to people in their vicinity and providing support through livelihood activities and supports. They also highlighted the intersectoral interventions within their purview that targeted education, income security, community engagement, transportation and access to essential health services, regulating access to substances, community awareness generation and de-stigmatisation etc.<br>
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Figure 9 shows the summary of different proposed solutions shared by panchayat members. The size of the text represents the frequency of the solution observed across groups.<br>
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[see PDF report for details of Figure 9]<br>
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<b>Chapter 6: Our learning and reflections</b><br>
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In this chapter, we present a synthesis of our insights and reflections gained during the development and the pilot testing of tools.<br>
<br>
<b>Storytelling game<br>
<i>Accessibility of the tools</i></b><br>
Overall, the participants were able to engage with the game. They articulated stories of their experiences related to the actors/institutions represented in the booth. We made a few changes during the process when we found few participants feeling difficulty in engaging in the game due to the terminology used. During the workshops, some participants found the term “kahaniya,” which translates to stories in Hindi, to be confusing, perceiving it more as a metaphor for fictional tales or imaginations. Consequently, this term was replaced with “anubhav,” meaning experience. Additionally, the assets like prompt cards, booth cards and language within the game were adjusted to emphasize “experience with stakeholders in relation to accessing mental health,” rather than solely focusing on stakeholder names. This led to making the game format more accessible for PLEs and caregivers.<br>
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<i><b>Experiential tools versus traditional approaches</b></i><br>
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<b>Power of storytelling </b><br>
Mental health is a deeply stigmatised subject which inhibits open conversations across contexts due to the fear of judgment or shame. Storytelling serves as a powerful medium to overcome this stigma around mental health by creating a space wherein participants share and listen to stories of personal experiences. Further, since the tool does not require any technical expertise, its scope can be broadened specifically to communities with limited literacy and/or knowledge of policy processes. Stories, being universal, hold particular resonance in societies with rich cultural traditions of oral histories and storytelling.<br>
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<b>Manifestation of solidarity</b><br>
The tool facilitates a conducive environment for sharing personal narratives by ensuring that community members share and listen to stories in pairs rather than in groups. Participants through the storytelling workshops expressed a shared sense of understanding and resonance with the emerging narratives. The tool was able to build a collective understanding of systemic challenges in accessing mental health services, shifting away from the perception of mental health issues as solely individual challenges.<br>
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This is strengthened during the debrief conducted after each workshop, where listeners summarize different stories and the storytellers talk about their experiences of sharing stories with the listeners. This provides space to the participants to reflect on their stories and identify policy insights such as specific gaps, solutions and pathways for policy interventions to address their challenges.<br>
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<i><b>Processes for utilising these tools</b></i><br>
<br>
<b>Structuring the storytelling process</b><br>
Storytelling is a non-linear and free form exercise which can vary with each individual’s story arc. For many participants, restricting their narratives to each booth felt abrupt and incomplete. Accordingly, we briefed participants that if their story involved multiple actors, they could share different parts of the story in the relevant booths. Hence, developing a flexible storytelling structure that enables free flow is advisable.<br>
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Participants’ relationships with certain themes also influence the way stories are framed. For example, in the mental health contexts, families play a prominent role in negative and positive experiences. Hence, defining thematic areas in a way that resonates with the participants from the community is crucial to capture diverse narratives.<br>
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<b>Building relationships &amp; trust</b><br>
Engaging PLEs and caregivers in policy processes requires building a sustained relationship and trust. For recruiting the PLEs and caregivers for the storytelling game we coordinated with District Mental Health Programme (DMHP) through the State Health And Family Welfare Department. We also reached out to CBOs who were part of storytelling game to identify and recruit participants. During recruitment, it was vital to address participants’ concerns about sharing personal narratives, requiring multiple follow-up calls and discussions. At workshops, participants received detailed information sheets and consent forms before engaging in gameplay.<br>
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We also introduced ice-breakers, context setting, game demos, and debriefing sessions to align participants’ understanding of mental health and help the participants bond with each other without the fear of being judged. The tool, by excluding ‘experts’ or ‘outsiders’ enabled participants to freely share their stories with others who are from similar contexts.<br>
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<b>Support needs of people with lived experience &amp; caregivers</b><br>
Participants with lived experience of mental health conditions were at different stages of their treatment and recovery journeys. While some participants could actively engage others with high support needs faced challenges due to communication and capacity constraints. As a result, the tool’s scope was limited to persons who did not have high support needs. To provide support, we also merged PLE and caregiver workshops thus accommodating larger groups (up to n=35) without compromising insights.<br>
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Stigma hindered PLEs and caregivers in sharing their stories since experiences could not be fictionalised and people attending the workshop feared the possibility of stigma and shame.  To address this, we emphasised mental health as a universal issue (“everyone experiences poor mental health”) during context setting and encouraged participants to fictionalise their stories maintaining confidentiality.<br>
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<b>Facilitator’s role </b><br>
The facilitator’s role is crucial in ensuring fidelity to the project, meaningful participation and synthesising emergent insights in accordance with workshop objectives. In this context, facilitators adopted a directive approach setting context about mental health, demonstrating gameplay and providing clear and specific prompts to overcome linguistic, cultural and conceptual barriers.<br>
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In the workshops, participant engagement with the storytelling game varied based on their identity and positionality within the group. Often women preferred speaking with women facilitators and caregiver-care recipient dynamics also influenced participation. In such cases, we engaged with PLEs separately thus enabling them to express themselves openly.<br>
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During the reflections and debriefing the facilitators need to be trained in safeguarding/ grounding techniques to address any concerns that arise during the process, and further explore specific policy insights emerging from the different stories.<br>
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<b>Digital simulation game and solutioning tool<br>
<br>
<i>Accessibility of the tools</i></b><br>
Across all three workshops, the variation in the tool’s application was seen among workshop participants primarily in terms of digital literacy. The tool was modified after the first workshop to make it easier for first-time computer users to still have engaging gameplay. We introduced –

 A digital orientation for participants to use the tool.
 A demonstration of how to navigate the interface was done using a presentation.
 A primer simulation that allowed participants to click through the tool while simultaneously providing context on the objective of the session along with background information on mental health care and the rights of PLEs.

For participants who were hesitant while using the digital tool, we provided one-on-one support with facilitators talking them through the process.<br>
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<i><b>Experiential tools versus traditional approaches</b></i><br>
<br>
<b>Power of ‘play’ </b><br>
Games and simulations draw upon the power of engaging in ‘play’ which enables individuals to suspend their own reality and immerse themselves in another individual’s world (real or imagined). This facilitates an opening of one’s mind to think more freely, dissociate from one’s own subjective experiences and relate to another person’s story or journey without overidentifying with the same. During our workshops with panchayat members we found that post the simulation game, participants were able to reflect on their role as village council leaders and identify policy solutions for challenges they experienced while playing the simulation game.<br>
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<b>Distil complex social and policy issues</b><br>
Simulations are time effective and impactful tools for unpacking complex multi-layered social issues within a short period. The digital simulation game through an immersive experience supports participants in understanding the diverse actors and the obstacles and support systems in an individual’s mental health journey. In comparison, conventional training sessions or workshops are of a much longer duration, less engaging and cognitively draining which inhibits empathetic engagement with the lived experiences of individuals on a highly stigmatised issue.<br>
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<b>Coupling simulations with solutioning</b><br>
The approach to combining the simulation tool with a group solutioning workshop allowed the participants to first immerse themselves in the game individually. While the initial experience of playing the simulation game can be isolating, following this with the group solutioning exercise motivated participants to share their insights and collectively identify policy solutions to the challenges experienced as part of the simulation game. The tool and workshop were also very effective in generating intersectoral insights.<br>
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<i><b>Processes for utilising these tools</b></i><br>
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<b>Context setting </b><br>
There was variation in the level of understanding of mental health among participants across workshops. This played a role in how effectively participants engaged with the simulation tool and thereafter solutioning. In the subsequent workshops, an interactive context setting exercise was conducted at the start of the session to glean from participants their understanding of mental health. This effectively oriented participants as they moved to the simulation tool and helped them identify challenges with each story.<br>
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<b>Planning for bureaucratic processes</b><br>
Any policy-making process in India or a similar low- and middle- income country (LMIC) context is contingent on various dependencies such as standard bureaucratic processes which can vary across states, districts, specific departments and the political will of officials. Thus, strengthening an ongoing relationship with government stakeholders is critical for planning and implementing such policy engagement processes.<br>
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<b>Iterating and embedding participatory tools in policy processes as per defined objectives and outcomes</b><br>
To leverage the maximum potential of such tools it is crucial to embed them in sustained policy processes with specified objectives and outcomes (rather than one-off engagements). This will ensure that the data or insights obtained are specific to the defined objectives and outcomes at each stage of the process. These tools are also iterative and their substantive content such as thematic areas, individual user journeys, game dilemmas/choices, etc. can be curated, modified and made bespoke as per the objectives, defined policy area and expected outcomes of the process.<br>
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<b>The Project Team</b><br>
Centre for Mental Health Law &amp; Policy, Indian Law Society, Pune<br>
Thumbi Labs Private Limited, Bangalore