Abstract
This study evaluated a pair of video games called the RePresent games that taught users how to represent themselves in civil court. A quasi-experimental study was conducted that compared 69 RePresent game users and 78 non-game users with civil legal issues across four U.S. states on legal, mental health and psychosocial outcomes over 3 months. The results revealed that RePresent game users reported greater legal knowledge, better mental health and higher quality of life than non-game users across time, and a greater rate of improvement in legal knowledge than non-game users over time. These findings suggest that gamifying education about legal procedures for the general public holds great potential in helping individuals obtain self-help legal assistance although some formal mental health treatment may be needed for many seeking legal aid.
Key words: civil law, legal aid, mental health, therapeutic jurisprudence, video games
Introduction
Social determinants of health are increasingly being recognized as important for individual, public and population health (Adler et al., 2016; Braveman & Gottlieb, 2014; Gottlieb et al., 2013). Civil legal issues are an important but often unrecognized social determinant of health. Civil legal issues can undermine housing, income, employment, family, health care and physical safety, creating adverse social and living conditions for the parties involved (Legal Services Corporation, 2007; Sandel et al., 2010). The vast majority of parties with civil legal issues in the United States use pro se representation – that is, they represent themselves instead of hiring professional legal representation. Unlike criminal courts where defendants are guaranteed an attorney if they cannot afford one, there is generally no right to an attorney for litigants in civil legal cases in the United States with a few exceptions such as the Right to Counsel movement in New York. Vulnerable populations, such as those in poverty or who have serious medical or mental health illnesses, have been found to have higher rates of civil legal issues and a greater incidence of negative consequences from these issues (Sandefur, 2015).
The number of civil litigants choosing to self-represent in court has grown significantly in the past decade (Henschen, 2018; Landsman, 2009). However, many parties with civil legal issues lack knowledge about their rights and responsibilities, legal procedures and processes, and where and how to seek legal assistance (Kim, 1987; Teufel et al., 2015). Legal aid, defined as legal assistance provided to individuals who are unable to afford legal representation, is provided in communities across the country by public interest law firms and community legal clinics to the public free or at a reduced cost (Udell, 2016). Legal aid is a resource that many individuals rely on for assistance with their civil legal issues, and it can take many forms, from brief legal advice through a hotline, to in-person consultation, to full legal representation. Studies have shown that providing legal aid to individuals who need it can improve their health and well-being (O'Sullivan et al., 2012; Retkin et al., 2007; Ryan et al., 2012; Tsai et al., 2017). In fact, legal scholars have begun to pay attention to the therapeutic or antitherapeutic effects of legal processes and procedures on the psychological outcomes of the parties involved, an interdisciplinary field called therapeutic jurisprudence (Wexler, 2008).
However, legal aid offices throughout the country are understaffed, inundated with requests, and do not have the resources to fully attend to each case. The federally-funded Legal Services Corporation (LSC), which is the largest single funder of civil legal aid in the country, issued an important report in 2017 entitled ‘The Justice Gap’, which reported that 71% of low-income households experienced at least one civil legal problem in the past year, and 86% of civil legal problems reported by low-income Americans received inadequate or no legal help (Legal Service Corporation, 2017). In 2017, low-income Americans will approach LSC-funded legal aid organizations with an estimated 1.7 million problems but less than half of these problems will receive adequate legal help due to lack of resources (Legal Service Corporation, 2017).
Legal empowerment is a growing concept that is being recognized by governments around the world and can be defined as the use of law to ethically strengthen disadvantaged populations and their control over their lives (Golub, 2010). A recent review of 90 studies reported on a wide range of legal empowerment interventions, such as increasing legal literacy, employing community-based paralegals and enacting right-to-information laws, but the authors concluded that there is need for more evidence-based practices (Goodwin & Maru, 2017).
There have been various efforts to provide legal aid resources in different modalities. For example, law library resource centers include books and electronic resources, community-based paralegals, workshops, computer-based interactive forms and services co-located with court locations (American Bar Association, n.d.). There are also paid educational programs, free pro se legal clinics offered in many cities, and social media sites that offer assistance for pro se litigants (e.g. Facebook group, YouTube videos). There has been development of some online video games that teach individuals general information about the legal system (Hagan, 2017). However, we know of no previous development of video games that teach users specifically about the actual mechanics of pro se representation in civil legal proceedings – games that teach people the procedures of attending civil court without a lawyer.
In the current study, we evaluated a pair of online video games called the RePresent games that offer gamified educational content on pro se representation and teach users about civil legal issues and procedures. The RePresent games were made available online to the general public in four U.S. states (Connecticut, Massachusetts, Maine and New Hampshire). Using a quasi-experimental two-group design, we compared RePresent game users and a comparison group of non-game users on baseline characteristics and legal, mental health and psychosocial outcomes after 3 months. We hypothesized that RePresent gameplay would be associated with greater improvements in legal knowledge and mental health than in non-game users.
Method
Games description
The RePresent games are two games called RePresent and RePresent: Renter (the latter herein referred to simply as Renter). These are both digital interactive video games created for the purpose of educating the public about how to self-represent in civil legal court. Most self-represented parties lack experience advocating for themselves in a formal setting, which can be challenging in a court environment with much at stake. The RePresent games provide a simulated environment to learn about the process, how to prepare for it and how to handle the basic mechanics of courtroom processes. The games focus on providing self-represented parties with general skills and tasks required for adjudicatory proceedings, such as what to bring to court, how to address the judge, how to cross-examine a witness and how to offer documents into evidence. The RePresent games do not provide legal advice and were designed to only provide information about procedures. The games provide a basic, retainable understanding of how to prepare for and self-advocate in court.
The original RePresent game was created in 2015 and has since been modified to RePresent 2.0, which was developed in 2017 with jurisdiction-specific versions for the states of Connecticut, Maine, Massachusetts and New Hampshire. In 2017, the RePresent platform was used to create a new game called RePresent: Renter. Renter is a more specific game designed to educate self-represented parties on how to navigate summary process eviction proceedings in housing court. Jurisdiction-specific versions of Renter were created for Connecticut and Maine. Both RePresent games are available on desktop/browser and iOS-based or Android-based products (e.g. smartphones, tablets). From January to May 2018, the RePresent game was played over 3000 times, and the Renter game was played over 500 times across states. Additional details about the RePresent games have been described elsewhere (Tsai et al., 2020).
Design and procedure
The RePresent games were made publicly available in the four aforementioned states in January 2018 on legal aid websites and downloadable as an app on Apple iTunes and Google Play Store. The RePresent games were marketed through flyers in legal aid offices, highlighted on legal aid websites and advertised in online ads, as well as social media.
A two-group pre-post research design was employed to compare adults with current legal issues who played any RePresent game and those who did not play any RePresent game on legal, mental and psychosocial outcomes. The two groups of participants were self-selected in a naturalistic manner. Users who accessed the RePresent games were invited to participate in the study through a link embedded at the start of the games. Non-game users who were seeking legal assistance were invited to participate in the study through a link advertised on the main legal aid website in each state. Eligibility for the study was individuals 18 years or older, English-speaking, living in the selected state and having at least one active civil legal issue (e.g. housing, family, criminal record, immigration, tax, or consumer debt, etc.).
Game and non-game user participants were asked to complete a baseline survey online that collected data on their demographic background, legal issues and their clinical and psychosocial status. Participants were then contacted 3 months later and were asked to complete a follow-up survey online. All participants provided informed consent and were compensated $10 at baseline and $20 at follow-up upon completion of each survey. Study procedures were approved by the institutional review board at Yale University School of Medicine.
Participants
Of 277 participants (136 game users and 141 non-game users) who were enrolled in the study and completed the baseline survey, 147 (53.1%) completed the 3-month follow-up survey and served as the main study sample in the current study. Compared to those lost to follow-up, completers were significantly more likely to have a Bachelor’s degree and less likely to have annual income more than $70,000 (p < .05); there were no other significant sociodemographic differences.
Of the 147 participants in this study, 94 (45 game users and 49 non-game users) were from Maine, 35 (18 game users and 17 non-game users) were from Connecticut, 11 (3 game users and 8 non-game users) were from New Hampshire, and 7 (3 game users and 4 non-game users) were from Massachusetts.
Measures
Legal issues and legal status were assessed with a checklist of possible legal issues (e.g. eviction, bankruptcy, consumer debt), and participants were asked to indicate which ones they were currently experiencing and which ones they had experienced in the past. For each current legal issue that participants reported, they were asked about the status of the case in terms of whether it was filed or awaiting court processes or whether an outcome had been determined (i.e. case won, case lost, neutral decision).
Legal knowledge and sense of procedural justice were assessed with two different scales. Participants were asked to rate how much they know about how to resolve their legal problem from 0 (nothing) to 4 (a lot). Participants were also asked to rate their sense of procedural justice using a 7-item measure adapted from the MacArthur Perceived Procedural Justice Scale (Lidz et al., 1995). This measure asked participants the extent to which they felt they ‘are able to express [their] views in the legal process’ and that the ‘legal process is ethical’. The mean of responses was calculated for a scale score.
Empowerment was assessed with an abbreviated 10-item Empowerment Scale (Rogers et al., 2010) designed to measure subjective feelings of empowerment. Participants were asked to rate their level of agreement on a 4-point scale from 1 (strongly agree) to 4 (strongly disagree) on various statements like ‘I am usually confident about the decisions I make’. After reverse-coding items, the mean of all item responses was calculated for a total score, with higher scores indicating greater levels of empowerment.
Self-efficacy was assessed with a 10-item General Self-Efficacy Scale (GSES; Sherer et al., 1982) that asked participants to rate statements like ‘I am a self-reliant person’ on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). Responses were summed for a total general self-efficacy score. The GSES is a widely used measure in clinical research with established reliability and temporal stability.
Mental health was assessed with several validated measures. Overall mental health was assessed with an abbreviated 14-item Behavior and Symptom Identification Scale (BASIS–24; Eisen et al., 2004), and the Patient Health Questionnaire–2 (PHQ–2; Kroenke et al., 2009) and the Generalized Anxiety Disorder-2 scale (GAD–2; Kroenke et al., 2007) were used to assess symptoms of major depression and generalized anxiety disorder, respectively. For both the PHQ–2 and GAD–2, scores ≥3 were indicative of a positive screen for major depression or generalized anxiety.
Any recent use of mental health services was assessed by asking participants yes/no whether they received any services for mental health problems in the past year or whether they received any services for substance abuse problems in the past year.
Substance abuse was assessed by asking participants how many days in the past 30 days they had more than two drinks of alcohol per day, and how many days in the past 30 days they had used any illegal drugs. Potential alcohol use problems were categorized as more than 7 days of alcohol use in the past 30 days. Potential drug use problems were categorized as any days of illegal drug use in the past 30 days.
Quality of life was assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form (Q-LES-Q–SF; Endicott et al., 1993). The Q-LES-Q–SF is a frequently used 14-item measure that asks participants about their satisfaction in the past week in various aspects of life – for example, work, social and family relationships, living situation. Participants were asked to rate their satisfaction in these areas from 1 (very poor) to 5 (very good). Responses were summed and transformed into a percentage of the maximum possible score as a total scale score.
Data analysis
Descriptive statistics were used to summarize the sociodemographic characteristics and legal issues of the total sample at baseline. Bivariate analyses using t tests and chi-square tests were conducted to compare RePresent game and non-game users on these sociodemographic characteristics and legal issues. Then, legal and psychosocial outcomes between RePresent game and non-game users at 3 months were analyzed using repeated measures analysis of covariance. Baseline differences between game and non-game users were entered as covariates to control for them in the analyses. Generalized estimating equation analyses were conducted to compare game and non-game users on substance abuse outcomes because these outcomes were categorical. All analyses were conducted using IBM SPSS Version 23.0.
Results
As shown in Table 1, the majority of participants were white, female, 25–44 years old, employed with annual incomes $15,000–$70,000 and with no lifetime history of incarceration or homelessness. The most common legal problems reported at baseline were related to money/debt, family and apartment housing. There were no significant differences in sociodemographic characteristics between RePresent game and non-game users. However, RePresent game users were significantly more likely to have current legal issues related to apartment housing and estate/probate and less likely to have current legal issues related to money/debt. RePresent game users were also significantly more likely to have had past legal issues related to apartment housing and taxes, but less likely to have had past legal issues regarding family law. At baseline, both RePresent game and non-game users reported currently having an average of more than one legal issue (total sample mean = 1.5, SD = 1.1, range = 1–6).
Table 1.
Baseline sociodemographic characteristics and legal status of RePresent game and non-game users.
| Game users (n = 69) Mean/Count (SD/%) |
Non-game users (n = 78) Mean/Count (SD/%) |
Test of difference |
|
|---|---|---|---|
| Age | |||
| 18–24 years | 1 (1.4) | 7 (9.0) | 4.31 |
| 25–34 years | 30 (43.5) | 30 (38.5) | |
| 35–44 years | 25 (36.2) | 29 (37.2) | |
| 45–54 years | 10 (14.5) | 9 (11.5) | |
| 55 years or older | 3 (4.3) | 3 (3.8) | |
| Gender: Male | 31 (44.9) | 30 (38.5) | 0.63 |
| Ethnicity: White | 40 (58.0) | 53 (67.9) | 1.57 |
| Marital status: Married | 29 (42.0) | 37 (47.4) | 0.43 |
| Annual personal income | |||
| <$15,000 | 11 (15.9) | 13 (16.7) | 9.95 |
| $15,000–$30,000 | 14 (20.3) | 11 (14.1) | |
| $31,000–$50,000 | 23 (33.3) | 18 (23.1) | |
| $51,000–$70,000 | 13 (18.8) | 16 (20.5) | |
| $71,000–$90,000 | 6 (8.7) | 6 (7.7) | |
| $91,000–$110,000 | 1 (1.4) | 8 (10.3) | |
| >$110,000 | 1 (1.4) | 6 (7.7) | |
| Full/part-time employment | 58 (84.1) | 58 (74.4) | 2.07 |
| Ever been to jail | 11 (15.9) | 7 (9.0) | 1.65 |
| Ever been homeless | 11 (15.9) | 18 (23.1) | 1.17 |
| Current legal problem(s) | |||
| Money or debt | 23 (33.3) | 31 (39.7) | 0.65 |
| Family | 16 (23.2) | 31 (39.7) | 4.61* |
| Apartment housing | 23 (33.3) | 12 (15.4) | 6.50* |
| Home foreclosure | 4 (5.8) | 4 (5.1) | 0.03 |
| Immigration | 2 (2.9) | 2 (2.6) | 0.02 |
| Criminal record history | 5 (7.2) | 6 (7.7) | 0.01 |
| Estate/probate | 7 (10.1) | 2 (2.6) | 3.66* |
| Tax | 10 (14.5) | 6 (7.7) | 1.75 |
| Unemployment or WC | 6 (8.7) | 8 (10.3) | 0.10 |
| Criminal problem | 5 (7.2) | 7 (9.0) | 0.15 |
| Other | 2 (2.9) | 7 (9.0) | 2.35 |
| Total no. of problems | 1.5 (1.3) | 1.5 (1.1) | 0.03 |
| Past legal problem(s) | |||
| Money or debt | 37 (53.6) | 36 (46.2) | 0.82 |
| Family | 11 (15.9) | 25 (32.1) | 5.14* |
| Apartment housing | 26 (37.7) | 10 (12.8) | 12.24** |
| Home foreclosure | 1 (1.4) | 6 (7.7) | 3.15 |
| Immigration | 5 (7.2) | 2 (2.6) | 1.77 |
| Criminal record history | 5 (7.2) | 6 (7.7) | 0.01 |
| Estate/probate | 2 (2.9) | 1 (1.3) | 0.48 |
| Tax | 23 (33.3) | 4 (5.1) | 19.43** |
| Unemployment or WC | 5 (7.2) | 7 (9.0) | 0.15 |
| Criminal problem | 5 (7.2) | 10 (12.8) | 1.24 |
| Other | 1 (1.4) | 6 (7.7) | 3.15 |
| Total no. of past problems | 1.8 (0.9) | 1.4 (1.0) | 1.93 |
Note: N = 147. WC = workers’ compensation. All tests of difference values are χ2 values except for t-tests of difference for “total no. of problems” and “total no. of past problems”.
*p < .05. **p < .001.
Table 2 shows changes in legal knowledge, sense of procedural justice, mental health and other psychosocial characteristics of RePresent game and non-gamer users over the 3-month period of the study. Controlling for baseline differences in current and past legal issues, both game and non-game users reported significant improvements in mental health over time as reflected by BASIS–24 scores (i.e. significant time effect). RePresent game users reported significantly greater legal knowledge, better mental health as reflected by lower BASIS–24 scores, PHQ–2 scores and GAD–2 scores, and higher quality of life across time than non-game users (i.e. significant group effects). While RePresent game users did report a significantly greater rate of increased legal knowledge than non-game users over time (i.e. significant Group × Time interaction effect), game users did not report a significantly greater rate of improvement in mental health or substance abuse outcomes than non-game users. Interestingly, both game and non-game users reported a significant decrease in their sense of empowerment and an increase in potential alcohol use problems across time.
Table 2.
Legal and psychosocial outcomes over time of RePresent game and non-game users.
| Game users (n = 69) |
No game users (n = 78) |
Group effect F |
Time effect F |
Group × Time interaction effect F |
|||
|---|---|---|---|---|---|---|---|
| Baseline | 3 months | Baseline | 3 months | ||||
| Self-rating of legal knowledge, M (SD) | 3.25 (0.95) | 3.88 (1.06) | 2.75 (0.84) | 3.14 (1.01) | 15.50*** | 7.85*** | 3.07* |
| Procedural Justice Scale, M (SD) | 4.06 (1.00) | 4.15 (1.23) | 3.75 (1.13) | 3.77 (1.12) | 2.70 | 1.40 | 1.70 |
| General Self-Efficacy Scale, M (SD) | 30.20 (3.92) | 29.50 (4.26) | 29.36 (5.88) | 30.00 (5.12) | 0.85 | 1.16 | 0.14 |
| Empowerment Scale, M (SD) | 3.04 (0.46) | 2.97 (0.37) | 3.08 (0.51) | 2.89 (0.47) | 1.73 | 12.91*** | 1.33 |
| BASIS–24, M (SD) | 1.92 (0.56) | 1.86 (0.52) | 2.34 (0.66) | 2.12 (0.63) | 29.56*** | 5.74* | 3.45 |
| PHQ–2, M (SD) | 3.74 (1.49) | 3.46 (1.11) | 4.15 (1.69) | 3.95 (1.51) | 7.98** | 0.70 | 0.24 |
| GAD–2, M (SD) | 3.60 (1.57) | 3.57 (1.55) | 4.21 (1.77) | 3.94 (1.56) | 8.54** | 0.06 | 0.01 |
| Q-LES-Q–SF, M (SD) | 0.67 (0.16) | 0.65 (0.15) | 0.56 (0.15) | 0.60 (0.18) | 18.72*** | 5.02* | 6.23* |
| Alcohol use problems, n (%) | 24 (36.2) | 28 (40.6) | 3 (3.8) | 10 (12.8) | 10.28** | 5.09* | 2.99 |
| Drug use problems, n (%) | 22 (31.9) | 15 (21.7) | 38 (48.7) | 41 (52.6) | 9.67** | 0.43 | 3.08 |
Note: N = 147. BASIS–24 = Behavior and Symptom Identification Scale; PHQ–2 = Patient Health Questionnaire–2; GAD–2 = Generalized Anxiety Disorder Scale; Q-LES-Q–SF = Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form.
*p < .05. **p < .01. ***p < .001.
Among RePresent game users, there were 93 cases that were being filed or awaiting court processes at baseline and at 3 months; there were 3 (3.2%) cases won, 4 (4.3%) cases lost and 5 (5.4%) neutral decisions. Among non-game users, there were 110 cases that were being filed or waiting court processes at baseline and at 3 months; there were 3 (2.7%) cases won, 6 (5.5%) cases lost and 13 (11.8%) neutral decisions. There was no significant difference in legal outcomes between game and non-game users, χ2 = 0.42, with the majority of cases for both game and non-game users still being filed or awaiting court processes at 3-month follow up.
Discussion
This is the first outcome evaluation of the RePresent games, which were made publically available in four New England states through online websites and native mobile phone apps. The RePresent games are intended to be rolled out to other states across the country so this evaluation informs the utility of the roll-out. The evaluation revealed several interesting findings. For one, there were no sociodemographic differences between RePresent game and non-game users seeking civil legal assistance. For example, game users were not only young males, which is the typical demographic profile of video game players (Griffiths et al., 2012), but instead adults from various sociodemographic groups played the RePresent games. This finding is encouraging as it suggests that games like the RePresent games can have broad appeal and be used as an educational tool for adults from diverse backgrounds.
A second notable finding was that RePresent game users showed greater improvements in legal knowledge over 3 months than did non-game users. The RePresent games were designed to provide legal knowledge to users in a gamified fashion, so this finding was encouraging and extends previous research finding that gamifying psychoeducation can be effective (Hidalgo-Mazzei et al., 2018). However, our study hypothesis was only partially supported since we did not find that RePresent game users reported greater improvements in mental health or quality of life than non-game users over time. RePresent game users did start with greater legal knowledge, mental health and higher quality of life than non-game users before playing the games and were able to maintain this higher status at 3-month follow-up, suggesting that game users were more high functioning. Thus, it seems the educational content provided by the RePresent games did not directly have psychological benefits for users, which may be due to the limited 3-month time frame of the study when the majority of cases were still pending and awaiting a decision since civil court matters can take months to resolve. In addition, providing litigants legal knowledge does not necessarily mean litigants will apply their learned knowledge or that it will result in faster resolution of their legal problems; but certainly pending legal problems may serve as a source of ongoing distress.
There may be some behavioral health implications of our study. Game and non-gamer users reported high levels of distress, and many may benefit from formal mental health treatment. One previous study found that among adults seeking civil legal assistance, high rates of untreated mental health (>40%) and substance use disorders (>20%) were found (Tsai et al., 2020). Civil legal settings may serve as a possible entry point for intervention that should be further explored. There may be opportunities to integrate screening and referral procedures to mental health and substance abuse treatment for those seeking legal aid. It may also be possible to adapt games like the RePresent games to include elements to facilitate access to treatment.
A third finding, which was unexpected, was that both RePresent game and non-game users reported decreased sense of empowerment and increased alcohol use over time. There was no evidence that this was the result of playing the RePresent games or receipt of any other legal aid. It is not exactly clear why this occurred, but it could be speculated that it may be related to the long legal process of filing and waiting for cases to be decided, and the impact such uncertainty can have on important life factors such as housing and family matters. The majority of cases after 3 months was still pending, and this long process may be demoralizing regardless of any legal knowledge gained. There may also be a sense of powerlessness that occurs after one receives legal assistance and realizes the constraints of the law, no matter how much assistance is provided. It is also possible that because there was self-selection into the study, particularly motivated participants were enrolled, and so it might be expected that this motivation and sense of empowerment waned over time. Nonetheless, further research is needed on the psychological impact of this civil legal process and ways to reduce negative impacts, an area that could be focused on in future research on therapeutic jurisprudence.
There were several study limitations worth noting. First, this study may have missed the many individuals in the community who are unable to identify that they have a legal problem, do not know where to seek help, or do not have computers or smartphones to access the RePresent games. Second, long-term outcomes were not assessed, and we were limited to 3-month outcomes. Third, a small sample of participants was recruited with a range of civil legal issues, and further research is needed using a larger sample with greater specificity by focusing on certain types of civil legal issues to determine whether certain legal issues are more impacted by the RePresent games than others. Fourth, recruitment and assessment procedures with participants were conducted by email and online surveys, and it is unknown how these procedures affected the results compared to in-person recruitment and assessment procedures. These limitations notwithstanding, there were several strengths of the study, including the real-world setting of the evaluation as opposed to a contrived lab setting, recruitment of participants across four states, which increases generalizability, and evaluation of a new, innovative way to provide self-help legal aid to the public. In conclusion, the study findings suggest that games like the RePresent games can offer an inexpensive, easily accessible platform to provide legal guidance to the diverse adults and improve their knowledge of legal procedures to self-represent themselves in civil court. Many adults seeking legal aid may benefit from mental health treatment, and ways to possibly use these type of games to facilitate their access to care should be explored. Nonetheless, these games need to be continually improved upon in terms of user experience, effective features and educational content to target users in different regions and with different issues.
Acknowledgements
Special thanks to Stateside Legal Services of Connecticut, the NuLawLab and the Game Design Studio at Northeastern University School of Law, MassLegalHelp.org, New Hampshire Legal Aid, New Haven Legal Assistance and Pine Tree Legal Assistance.
Funding Statement
Funding for this project was provided by the Legal Services Corporation.
Ethical standards
Declaration of conflicts of interest
Jack Tsai has declared no conflicts of interest
Minda Huang has declared no conflicts of interest
Kathleen Daniels has declared no conflicts of interest
Casper Harteveld has declared no conflicts of interest
Dan Jackson has declared no conflicts of interest
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional review board at Yale University School of Medicine as protocol no. 2000022410 and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study
References
- Adler, N. E., Cutler, D. M., Jonathan, J. E., Galea, S., Glymour, M., Koh, H. K., & Satcher, D. (2016). Addressing social determinants of health and health disparities (Vital Directions for Health and Health Care Initiative, Issue). [Google Scholar]
- American Bar Association. (n.d). Affordable legal services. American Bar Association. Retrieved February 8, from https://www.americanbar.org/groups/delivery_legal_services/resources/programs_to_help_those_with_moderate_income/
- Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(1_suppl2), 19–31. 10.1177/00333549141291S206 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Eisen, S. V., Normand, S. L., Belanger, A. J., Spiro, A., & Esch, D. (2004). The revised Behavior and Symptom Identification Scale (BASIS-R): Reliability and validity. Medical Care, 42(12), 1230–1241. [DOI] [PubMed] [Google Scholar]
- Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993). Quality of life enjoyment and satisfaction measure: A new measure. Psychopharmacology Bulletin, 29(2), 321–326. [PubMed] [Google Scholar]
- Golub, S. (2010). What is legal empowerment? An introduction. In Golub S. (Ed.), Legal empowerment: practitioners’ perspectives (pp. 9–18). International Development Law Organization. [Google Scholar]
- Goodwin, L., & Maru, V. (2017). What do we know about legal empowerment? Mapping the Evidence. Hague Journal on the Rule of Law, 9(1), 157–194. 10.1007/s40803-016-0047-5 [DOI] [Google Scholar]
- Gottlieb, L., Sandel, M., & Adler, N. E. (2013). Collecting and applying data on social determinants of health in health care settings. JAMA Internal Medicine, 173(11), 1017–1020. [DOI] [PubMed] [Google Scholar]
- Griffiths, M. D., Kuss, D. J., & King, D. L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8(4), 308–318. [Google Scholar]
- Hagan, M. (2017). Learning law better: Law games and beyond. Margaret Hagan. Retrieved February 8, from http://www.openlawlab.com/project-topics/learning-law-better/
- Henschen, B. (2018). Judging in a mismatch: The ethical challenges of pro se litigation. Public Integrity, 20(1), 34–46. 10.1080/10999922.2016.1272438 [DOI] [Google Scholar]
- Hidalgo-Mazzei, D., Reinares, M., Mateu, A., Nikolova, V. L., Bonnín, C. d M., Samalin, L., García-Estela, A., Pérez-Solá, V., Young, A. H., Strejilevich, S., Vieta, E., & Colom, F. (2018). OpenSIMPLe: A real-world implementation feasibility study of a smartphone-based psychoeducation programme for bipolar disorder. Journal of Affective Disorders, 241, 436–445. 10.1016/j.jad.2018.08.048 [DOI] [PubMed] [Google Scholar]
- Kim, H. B. (1987). Legal education for the pro se litigant: A step towards a meaningful right to be heard. The Yale Law Journal, 96(7), 1641–1660. 10.2307/796497 [DOI] [Google Scholar]
- Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50(6), 613–621. [DOI] [PubMed] [Google Scholar]
- Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146(5), 317–325. 10.7326/0003-4819-146-5-200703060-00004 [DOI] [PubMed] [Google Scholar]
- Landsman, S. (2009). The growing challenge of pro se litigation. Lewis and Clark Law Review, 13(2), 439–460. [Google Scholar]
- Legal Service Corporation (2017). The justice gap: Measuring the unmet civil legal needs of low-income Americans. https://www.lsc.gov/sites/default/files/images/TheJusticeGap-FullReport.pdf
- Legal Services Corporation (2007). Documenting the justice gap in American. Legal Services Corporation. Retrieved October 1, from http://www.lsc.gov/justicegap.pdf
- Lidz, C. W., Hoge, S. K., Gardner, W., Bennett, N. S., Monahan, J., Mulvey, E. P., & Roth, L. H. (1995). Perceived coercion in mental hospital admission: Pressures and process. Archives of General Psychiatry, 52(12), 1034–1039. [DOI] [PubMed] [Google Scholar]
- O'Sullivan, M. M., Brandfield, J., Hoskote, S. S., Segal, S. N., Chug, L., Modrykamien, A., & Eden, E. (2012). Environmental improvements brought by the legal interventions in the homes of poorly controlled inner-city adult asthmatic patients: a proof-of-concept study. The Journal of Asthma: official Journal of the Association for the Care of Asthma, 49(9), 911–917. [DOI] [PubMed] [Google Scholar]
- Retkin, R., Brandfield, J., & Bacich, C. (2007). Impact of legal interventions on cancer survivors. [Google Scholar]
- Rogers, E. S., Ralph, R. O., & Salzer, M. S. (2010). Validating the empowerment scale with a multisite sample of consumers of mental health services. Psychiatric Services (Washington, D.C.), 61(9), 933–936. [DOI] [PubMed] [Google Scholar]
- Ryan, A. M., Kutob, R. M., Suther, E., Hansen, M., & Sandel, M. (2012). Pilot study of impact of medical-legal partnership services on patients’ perceived stress and wellbeing. Journal of Health Care for the Poor and Underserved, 23(4), 1536–1546. [DOI] [PubMed] [Google Scholar]
- Sandefur, R. L. (2015). What we know and need to know about the legal needs of the public. South Carolina Law Review, 67, 443–459. [Google Scholar]
- Sandel, M., Hansen, M., Kahn, R., Lawton, E., Paul, E., Parker, V., Morton, S., & Zuckerman, B. (2010). Medical-legal partnerships: Transforming primary care by addressing the legal needs of vulnerable populations. Health Affairs (Project Hope), 29(9), 1697–1705. [DOI] [PubMed] [Google Scholar]
- Sherer, M., Maddux, J. E., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R. W. (1982). The self-efficacy scale: Construction and validation. Psychological Reports, 51(2), 663–671. 10.2466/pr0.1982.51.2.663 [DOI] [Google Scholar]
- Teufel, J., Mace, S., Michman, J., Atkins, D., & Dausey, D. J. (2015). Legal aid inequities predict health disparities. Hamline Law Review, 38(2), 329–360. [Google Scholar]
- Tsai, J., Huang, M., Huang, B., Daniels, K., Harteveld, C., & Jackson, D. (2020). Psychosocial and mental health characteristics of RePresent game users. Journal of the American Academy of Psychiatry and the Law, 48(3), 335–344. [DOI] [PubMed] [Google Scholar]
- Tsai, J., Middleton, M., Villegas, J., Johnson, C., Retkin, R., Seidman, A., Sherman, S. E., & Rosenheck, R. A. (2017). Medical-legal partnerships at Veterans Affairs medical centers improved housing and psychosocial outcomes for vets. Health Affairs (Project Hope), 36(12), 2195–2203. [DOI] [PubMed] [Google Scholar]
- Udell, D. (2016). The civil legal aid movement: 15 initiatives that are increasing access to justice in the United States (Impact: Collected essays to expanding access to justice, Issue). [Google Scholar]
- Wexler, D. B. (2008). Two decades of therapeutic jurisprudence. Touro Law Review, 24, 17–29. [Google Scholar]