Challenging Dogma


Monday, May 7, 2012

The Failure of Gamification in Fitness Behavior Modification From The Perspective of Social-Cognitive Theory - James Henry Steinberg


1.       Emergence of Gamification
            Obesity and metabolic syndrome pose a crisis for the American health care system and its public, in terms of both cost and comorbidities. In the preceding quarter century, the entirety of the U.S. population weight distribution has shifted upward (1); today more than two thirds of the adult population is overweight or heavier (2). Diabetes Mellitus, the most prominent manifestation of metabolic syndrome, has increased in its proportion of U.S. adults from 3.7% in 1980 (age-adjusted) to 8.7% in 2010 (age-adjusted)(3).
            Behavioral approaches towards weight loss have thus far failed: over 80% of individuals return to pre-weight loss levels of body fat after otherwise successful regimens, from a variety of approaches(4). Due to this persistent failure, there has been an increased move away from an individual focus on obesity, to the examination of the “obesogenic environment” - the genetic and environmental factors that predispose people towards obesity (5,6).
            The most recent trend in fitness behavior modification involves “gamification” (7). Gamification involves the integration of game mechanics into marketing, health, web domains, etc. for the purpose of influencing and motivating groups of people. Gamification is built on the essential findings of behavioral biologists regarding operant conditioning. “Game” mechanisms are usually restricted to what are traditionally known as “role playing games” (RPGs). The role playing game genre is identified by incremental advances in game difficulty, coupled to incremental advances in the player’s efficacy (ability to overcame obstacles, exert his will, and achieve desired goals in the game), arriving in a predictable and systematic manner. Usually, the games are easy at first, with increasing effort required to achieve additional increments of efficacy later in the game.  These incremental increases in efficacy are colloquially termed “leveling,” as the in-game protagonist is assigned a “level” that indicates his efficacy. Games typically present a very simple sort of operant conditioning: perform action X (ordinarily “kill the monster”, although “record 5 push-ups” works just as well), and one receives positive reinforcement in the form of increased efficacy in one’s endeavors (increasing one’s “level”).
 A player’s belief in his ability to achieve his goals is ordinarily high in this context: action and achievement are linked in an obvious manner, entirely under the player’s control. Because the time and effort to achieve the next level are always readily apparent, it is a reward that can be considered “fixed” – there is no element of chance involved. The player knows exactly what he has to do, and how much of it, to achieve the next increase in game-efficacy (the equivalent of self-efficacy with regards to accomplishing in-game goals).
            RPGs also involve more complex conditioning mechanisms. Early behavioral biologists found that the schedule of reinforcement is important. If reinforcement ceases after a behavior has been linked to it, a behavior may be extinguished. Reinforcement can be spaced out (as “leveling” is in RPGs), though again – this can lead to extinction, if the reinforcement becomes too widely spaced relative to the positive value of the reinforcement. It has been found that the ideal schedule involves early fixed rewards, with decreasing frequency, and a transition into variable rewards. If the average number of awards over a unit of time is constant, but with large variance (meaning rather than 1 award every 5 minutes, there’s an average of 1 award of every 5 minutes, varying from every 1 minute to every 10 minutes), subjects are shown to be more strongly influenced by reinforcements that begin to arrive over long periods of time (8). Role playing games often incorporate this via in-game “items” for characters – game-efficacy increases in the symbolic form of clothing and armor for one’s in-game avatar. Some of these “items” are awarded in a fixed fashion, guaranteed on the completion of a certain in-game event. Others are variable: upon completing some in-game victory, a digital version of a die is rolled – giving high chances of a mediocre award, with smaller chances of correspondingly better awards. In some games, repeatedly completing these in-game events so as to roll and re-roll the die for chances at the best item becomes the entire point of the game. These awards are meaningful positive reinforcement because they are not cosmetic: they directly increase the player’s game-efficacy, enabling them to partake in more difficult challenges and explore more of the game.
            These increases in a player’s game-efficacy are directly tied into the standard mechanism for “reciprocal determinism” – the idea that a person is shaped by their environment and, likewise, shapes their environment. The challenges and obstacles in the game are distributed throughout discrete parts of the game that the player can access, avoid, and revisit at his desire. The positive reinforcement of the game comes through defeating challenges – finding some optimal ratio of challenge and victory. In the real game setting, the environment offers a gradient of difficulty, with cues to advance the player. The player, however, may opt not to follow such cues: if the advancement has grown too difficult, or some area holds a particular allure, the player may choose to dally there, increase his game-efficacy there (though at a slower pace than if he were seeking greater challenges), and move on later. This is ‘reciprocal’ in the sense that the game has a set of built-in environmental factors to manipulate the player’s progress and pleasure, yet at the same time the player has the ability to ignore these factors, increase his efficacy in an easier area, and then proceed. Proceeding into the new area later than one ought to have can entirely change the manner and pacing of obstacles presented. In effect, the player has changed his own game.
            Games have also begun to incorporate more social elements. “Achievements” are fixed events that, upon their completion in the game, usually are not linked to efficacy increases. Rather, they become visible over game-based social networks, showcasing one’s triumphs to their peers. In a dual role, it also serves to model to peers that the game in question is being played, and with some measure of dedication. This serves as a form of observational learning to encourage others to partake in the game in question.
            In short, the game-play mechanisms salient to driving user behavior include game-and-gamer reciprocal determinism; an optimal positive reinforcement schedule using both fixed- and variable-timing; meaningful positive reinforcements, in this context usually increasing the player’s game-efficacy; and social learning. The new trend of “gamification” has utilized these four mechanisms to attempt to manipulate user behavior, but has failed in regards to the first three.

2.      Examples of the Use of Gamification as a Public Health Intervention
            Gamification has attempted to incorporate each of these mechanisms. The most prominent example to date is the exercise gamification “Fitocracy.” The website involves a facebook-like social network, where users self-label as being interested in particular types of fitness activities (i.e., “powerlifters”). This serves to involve them in conversation with their cohort. The central function of the site, however, is the ability to record one’s workouts. Each exercise is worth points and these points add up to allow one to increase their “level.” One can also gain Achievements through particular routines (i.e. doing a bench press, a deadlift, and a squat press all in one week). One’s level and achievements are publicly displayed to one’s network. The leveling mechanism is thought to encourage exercise by providing a fixed positive reinforcement. To quote its creators, “what if fitness could be turned into a game? After all, both [Richard] and Brian understood how addictive it could be trying to get to that next level, beating that next boss, and completing that next quest… They also realized that the addiction that games create was the exact same addiction that drives their fitness efforts every day.” (9) The social components allow groups to act as models for observational learning, as well as incentivizing (one must gain the deadlift-squat-bench achievement not to be an outcast among powerlifters).
            Fitocracy serves as a prominent example, having been one of the first attempts to “gamify” public health, but it is hardly an anomaly. Design companies are now framing gamification as the “future of health care” (10). HopeLab hopes to combat child obesity with the “Zamzee”, a device students wear to track their physical activity. More active children get points, level up, show off on a social network, and purchase goods for “winning” (11). Zamzee’s approach is untenable however, in that creating tangible goods as a reward has worked in their limited (12-week, 350-subject) laboratory studies, but is something they are unable to scale for use with the general public. One of the largest has been the iPod-integrated Nike+, which uses a GPS sensor to track runners and later to upload their data, track statistics, join challenges, and connect (and compete) with other runners in the Nike network.
            Modern social gaming mechanics are attractive to those attempting to “hook” people into healthy activities. They seem to leverage the power of social influence (observational learning), as well as the various elements of reciprocal conditioning that have made otherwise-mindless games such as “Farmville” and “World of Warcraft” such runaway successes. If something as “boring” as Warcraft could be so addictive as to ruin lives (12), then why couldn’t such mechanisms be used to make fitness and health equally attractive?
           
3.      Flaws in the Use of Gamification as a Public Health Intervention
            Unfortunately, such “gamification” attempts take on the shape of cargo-cult science. Although they utilize the appearance of Social Cognitive Theory (SCT), they fail to implement the core mechanisms that actually drive behavioral change.
            3A. The Failure to Connect Game Mechanics to Intrinsically Valuable Awards
            The fundamental principle behind “leveling” is that it enhances both the player’s game-efficacy, as well as acting as positive reinforcement – improvement’s in a player’s efficacy also increase enjoyment of the play process. That is to say, that increasing “levels” in the game has no value in itself – it is valuable only as it empowers the player to accomplish other game actions that are pleasing. However, current gamification attempts have neglected the importance of linking levels to positive stimuli, and instead attempt positive reinforcement by awarding the “levels” themselves – in effect, offering to warm their participants with smoke instead of fire.
Fitocracy, for instance, provides points, levels, quests, and achievements, all tied into a social network. Theoretically one is driven to advance one’s exercise regime by chasing new quests and achievements, and stabilize it as a habit by chasing level advancement. It also takes advantage of the element of observational learning and social approval through the built-in social network: one’s achievements are broadcast to their peers while, simultaneously, one is constantly kept apprised of their peers’ achievements. However, the primary mechanism of positive reinforcement – the levels that one gains through physical activity – is entirely useless: there is precisely no difference at all between a level 30 individual (someone that has been actively fit for a significant period of time) and a level 3 individual (a novice). Advancing in levels offers no positive reinforcement aside from seeing that number creep upwards. Not only is the pleasure of watching a meaningless number increase minimal, but as the amount of exercise needed to increase levels grows larger with each successive level, the period between these “reinforcements” grows increasingly sparse, until extinction is more likely than actual reinforcement of the target behavior.
Much the same could be said of Zamzee, created by the non-profit HopeLabs with the explicit aim of helping children and teens manage their weight. It incorporates many of the standard gamification mechanisms, and it would seem to correct the primary deficit: points and levels ultimately lead to a “victory” condition that is connected with tangible rewards. However, where Fitocracy can handle essentially unlimited numbers of users, the non-profit Zamzee must now purchase and gift tangible goods. For their 350-subject test, they claim to have provided such rewards, without specifying what the rewards were. This is clearly an unscalable project, however: expanding this to teens en masse would require an enormously expensive outlay of products, or the cheapening of such rewards until they are no rewards at all. Although this nominally attempts to address the lack of intrinsic motivation, this positive reinforcement mechanism will not be deployable in a real-world setting: Zamzee essentially has no real positive reinforcement mechanism beyond points-keeping for its own sake.
Nike+ stands out slightly compared to the other two interventions, as it is more of an attempt at building brand loyalty than an active gamification program - although it has described itself as part of the “gamification” trend based on its Achievement program (akin to that used by Fitocracy), and the user statistic-tracking and sharing, which has given rise to a culture of achievement sharing and competition. Morever, it is relevant because of its emphasis on running: although it doesn’t seek to make people healthier, it does need its customers to continue running in order to build the brand-loyal social network Nike seeks. Nike+ has in fact been one of the few large corporations successful in using social networking to build brand loyalty, by using this approach (13). As such, its bottom line goal is still compatible with the other programs mentioned: drive people to continue performing a particular fitness activity through social-network based peer learning and positive reinforcement. However, Nike+ makes the same mistakes seen in Fitocracy and Zamzee: beyond the social value of being able to proclaim one has met some particular achievement, meeting the goals in the Nike+ “game” offer no real reinforcement that encourages sustained performance of the target activity. Between Fitocracy, Zamzee, and Nike+ one sees a cross-section of the largest current health-gamification efforts, both for- and non-profit, and yet the failure to use positive reinforcement consisting of actual positive stimuli rather than simple scorekeeping remains ubiquitous.
3B. Reinforcements Tend To Be On a Fixed, Not Variable, Schedule
The second major failing of current gamification attempts is the failure to use variable reinforcement as a supplement to fixed reinforcement schedules.  As Skinner showed, a rat will press a button endlessly if it is rewarded with a food pellet – but when those food pellets come too rarely, the rat will eventually stop pressing the button, in a phenomenon known as extinction. This is essentially fixed reinforcement: if the rat presses, then there will be a pellet, without doubt or variation. If, however, a food pellet is dropped every three presses on average, the rat will continue to press the button far longer – even as the average number of button presses for a food pellet increases. This is a variable reinforcement schedule: the rat doesn’t expect every press to result in a pellet but, rather, that enough presses will eventually produce a pellet.
Video games have successfully incorporated variable reinforcement (in the form of “items” awarded to one’s game avatar, with the quality of the awarded item being randomly determined), as a supplement to the fixed-schedule “level” system. Health gamification efforts, however, are strictly fixed: perform 20 pushups, get 40 points, 300 points needed for level 2. Fitocracy awards a constant number of points for each exercise which, when added up, award one with a new level. There is no unpredictability and no variation. This is fine for early levels, where working out for a few days can result in advancement, but once one has achieved “higher levels” and these achievements are few and far between (weeks or months apart), one is more likely to cause behavioral extinction than engagement. Zamzee awards points for activity in a likewise unvarying manner, which ultimately adds up to a prize. Nike+ awards achievements for certain runs (distance, time, calories, etc.) with no surprise achievements, variation, or other unexpected positive stimuli. Not only is the lack of a variable positive reinforcement not conducive to an optimal reinforcement schedule but, as the amount of time and effort between successive levels grows exceedingly long, the strictly fixed program may in fact result in extinction. The current lack of chance in reinforcement schedules is not only suboptimal – it may in fact be actively detrimental to the cultivation of the desired fitness behavior.
            3C. Lack of Reciprocal Determinism Fails to Cope with User Variety
The third major failing of current gamification efforts regards the absence of reciprocal determinism that is ordinarily found in a game setting. Reciprocal determinism in games is important in that one is dealing with an enormous variety of people of varying levels of skill, dedication, and time. If the challenges and reinforcements offered are not responsive to a person’s individual needs they are far less likely to be engaged. If a person is finding an average challenge, accompanied by average reward, overwhelmingly difficult that reward is unlikely to be sufficient positive reinforcement to encourage them to tackle additional ‘overwhelming’ challenges. Fitocracy, as a social network with an achievements and leveling system, offers challenges only in that it requires increasingly larger efforts in order to receive positive reinforcement. These rewards do not change the difficulty of any of a subject’s goals, nor does the subject have any ability to reshape his challenge environment. One cannot simply exercise further in an “easier” difficulty area, because there are no gradients in difficulty – one simply exercises, or one does not. And as there is no increase in game-efficacy (other than increased fitness), even “taking it easy” and advancing at a slower pace is without reward: the difficulty of challenges and goals is unresponsive to achievements and advancements (which ties back to the first point, that the achievements and advancements are merely numbers measuring engagement with the system, and not meaningful reinforcement). The player, having no ability to reshape his environment, cannot alter it to suit their particular needs or skill level. The same criticism holds for Zamzee and Nike+. Insofar as the only challenges introduced are the challenges of exercise, and a one-size-fits-all reinforcement schedule is applied, players are entirely unable to reshape their environment to produce an experience that is suitably positive to keep them engaged.
           
4.      Proposed Remedies for the Flaws of Gamification Theory to Promote Public Health
4A. Using Games, not Gamification, for User Interaction
The resolution to these problems is not to scrap the approach of gamification, but rather, to extend it to account for the elements of the Social Cognitive Theory model that are missing. The foremost necessity is to amend the lack of true incentives: “levels”, “points,” and so on cannot merely be metrics that take on the appearance of achievement and advancement.  One must also supplement the fixed leveling system with a variable system, to counter infrequent levels and possible extinction. Lastly, one must provide for some sort of reciprocal determinism, to allow players to create their own levels of difficulty.
The difficulty is posed by the fact that gamification platforms currently rely on only a single dimension of difficulty: physical exercise. The addition of an additional dimension – an actual game – would allow one to address the flaws in the current system. In this way, achieving “levels” in the health gamification, while not increasing one’s efficacy in the fitness-dimension, can be tied to in-game levels, allowing for increases in efficacy in the game-dimension. Such a change would turn the positive reinforcement of level gains into actual meaningful incentives. Additionally, fitness achievements could be linked to variable rewards in the game. Lastly, where reciprocal determinism is difficult to achieve in the fitness-dimension, one could do so in the game world. In brief, one could attach the health metric to an actual game that does fulfill the requirements of the Social Cognitive Theory, and rely on the game to drive behavioral change.
4B. Connecting Real-world Fitness to Games
There are multiple ways to attach the fitness behavior to a game. The most difficult approach would be to construct actual games, which receive information from a gamification platform and integrate it into the gaming experience. This would utilize all of the elements that actually created addictive video games to encourage fitness activities. In this case one would have a real game with all of the mechanisms of modern gaming built-in: social networks for observational learning and social outcome expectations, reciprocal determinism in the form of the game obstacles being faced, and variable reinforcement in-game coupled to the fixed advance of levels with one’s exercise.  Most importantly, leveling would now be tied to something positive and enjoyable: advancing in a fun game. This would be difficult to create wholesale, as creating long-lasting and successful video games is an extremely rare event, regularly achieved by only a handful of dedicated game companies.
On the other hand, licensing old and successful games that now exist in legacy but produce few sales for their parent company (e.g., Diablo 2, still engaging tens of thousands of players daily, a decade after release) could be a successful alternative, wherein the primary costs of development would become software engineering to link the in-game advancement-state to some health metric, and licensing costs. With such software engineering being a relatively simple feat (people create such programs as hobbies)(14), the only true stumbling block would be licensing fees. For games that produce little annual returns (i.e., Diablo 2 sales a decade after release) companies may be incentivized to ‘donate’ such licensing fees as a tax deduction or public relations maneuver. Player enrollment may even be increased if such health-game projects were released 6 months to 1 year prior to the release of a new sequel in the game series (i.e., the Diablo 2 Health game 18 months prior to the release of Diablo 3). As a form of marketing for both products, this may be even more attractive to the parent company.
4C. Partnering With Game Developers, not Games, to Avoid Obsolescence
            One could also attempt to remedy the failings in gamification platforms not by linking fitness metrics directly to a game, but by partnering with game platforms like facebook’s Rovio and Zynga, or  small “indie” game publishers that are currently creating armies of new games via platforms such as the iTunes App Store and Steam (15). Zynga, for example, offers in-game purchases using real-world money. However, insofar as these in-game items actually have unlimited supply, some small fraction of them could be “donated” to a public health program. Coupled to something like Fitocracy, some rewards may be achieved upon earning a level, with some others having a random chance of occurrence upon completion of achievements and quests (introducing our variable element). The game-external approach avoids the problem of games that become dated, as well as once more reintroducing the social elements, peer observational learning, and the other relevant elements of Social Cognitive Theory.
            4D. Using Games that already Cultivate SCT to Drive User Behavior
            The ideal situation is to engage with a game that already manipulates operant conditioning to create a Skinner Box effect, as well as the other components of the SCT model, and hook the gamified fitness platform into that ecology. For instance, Massively Multiplayer Online Games (MMOGs) are already built around the idea of addicting players with a combination of fixed positive reinforcement (leveling), variable positive reinforcement (item awards), observational learning of peers (in-game social networks, integrated with out-of-game social networks), reciprocal determinism (in-game difficulty scaling by choice of zoning and leveling rate), self-efficacy gains through repeat successes against incrementally difficult obstacles, collective efficacy (some obstacles must be faced with one’s in-game network), and incentives are provided primarily through the opportunity for item drops (an opportunity to roll the die on the variable reinforcement). These games often lack anything except these elements, arguably becoming not a game at all, and yet are wildly successful.
Through the integration of health metrics into such games one can make use of an already extent and extremely effective Skinner Box environment for addicting people into pursuing fitness. Mechanisms for convincing corporations to include such an element may be to encourage its use as a shield against litigation: game makers are already being sued for the dangers of their addictive games (16); a defense of keeping an eye on players’ well-being and encouraging public health may be a small investment towards deflecting significant costs in litigation.

5.      In Summation
The current trend towards gamification of health initiatives is based predominantly on the Social-Cognitive Theory of behavior, but fails to take into account the element of reciprocal determinism, does not provide for variable-schedule positive reinforcement to optimize reinforcement of target behaviors, and most crucially tends not to incorporate any real incentives – thus creating “positive reinforcement” with no positives. Gamification is lauded by marketing companies as using the adornment of games without the need for actual game-play, and yet in so doing misses out on what it is that actually causes behavioral repetition (17). The simplest method to address these short-comings is to look at extant games that have already successfully made use of these mechanisms, and target game developers and publishers for tying a fitness metric to these games. By taking full advantage of social cognitive theory, health initiatives will be able to draw upon successful methods for driving user behavior, rather than simply the cargo cult equivalent.

References:
1.       Ogden CL, Carroll MD, McDowell MA, Flegal K. Obesity among adults in the United States – no statistically significant change since 2003-2004. NCHS Data Brief No.1. 2007. http://www.cdc.gov/nchs/data/databriefs/db01.pdf Accessed April 23, 2012.
2.      Centers for Disease Control and Prevention. National Center for Health Statistics. Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, Trends 1960–1962 Through 2007–2008. http://www.cdc.gov/nchs/data/hestat/obesity_adult_07_08/obesity_adult_07_08.pdf Last Accessed April 23, 2012.
3.      Centers for Disease Control and Prevention. National Center for Health Statistics. Crude and Age-Adjusted Percentage of Civilian, Noninstitutionalized Adults with Diagnosed Diabetes, United States, 1980–2010. Atlanta, GA: CDC. http://www.cdc.gov/diabetes/statistics/prev/national/figageadult.htm
4.      McGuire MT, Wing RR, Klem ML, Hill JO (1999) Behavioral strategies of individuals who have maintained long-term weight losses. Obes Res 7: 334-341.
5.      Obesity ‘not individuals’ fault. BBC News. October 17, 2007. http://news.bbc.co.uk/2/hi/health/7047244.stm Accessed April 23, 2012.
6.      Chang BW, Christakis NA. Medical modeling of obesity: A transition from action to experience in a 20th century American medical textbook. Sociol Health Illn. 2002;24:151-177.
7.      Ferdinando, M. Development of a multichannel gamification platform. Politesi. http://hdl.handle.net/10589/22961 . Last accessed April 23, 2012.
8.     Ferster, C.B., & Skinner, B.F. (1957) Schedules of reinforcement. New York: Appleton-Century-Crofts.
9.      Fitocracy. “What is this crazy Fitocracy thing?” NY: Fitocracy. http://www.fitocracy.com/about-us/  Last accessed April 23 2012.
10.  Design Mind. “Gamification of Healthcare.” San Fransisco, CA: Frog Design. http://designmind.frogdesign.com/blog/the-gamification-of-healthcare.html. Last accessed April 23, 2012.
11.   HopeLab. “Innovative Solutions: Zamzee.” Redwood City, CA: Omidyar Group. http://www.hopelab.org/innovative-solutions/zamzee/. Last accessed April 24, 2012.
12.  Peters CS, Malesky LA. “Problematic Usage Among Highly-Engaged Players of Massively Multiplayer Online Role Playing Games.” CyberPsychology & Behavior. August 2008, 11(4):481-484.
13.  Schogel M, Herhausen D. Comarketing Capability and its Impact On Marketing Alliance Performance (pp. 350-351). In: Marketing Theory & Applications. Chicago, IL: American Marketing Association, 2010.
14.  System Softlab. “Artmoney.” Moscow, Russia: System Softlab. http://www.artmoney.ru/ Last accessed April 25, 2012.
15.   David Michael. Indie Game Development Survival Guide (Game Development Series). Charles River Media, August 2003.
16.  Kravets, David. Addicted Gamer Sues Game-Maker, Says ‘Unable to Function’. San Fransisco, CA: Wired Magazine. http://www.wired.com/threatlevel/2010/08/lineage11-addiction/ Last accessed April 26, 2012.
17.   Bunchball, Inc. Gamification 101: An Introduction to the Use of Game Dynamics to Influence Behavior. October 2010. http://www.bunchball.com/sites/default/files/downloads/gamification101.pdf . Last accessed April 26, 2012.

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1 Comments:

  • At August 18, 2012 at 11:23 AM , Blogger Mark Kaepplein said...

    An example of harmful gamification is the web site strava.com. Bicyclists compete with themselves and one another using cell phone GPS applications to transmit travel data to the web site. Parents of a San Francisco pedestrian killed by a cyclist racing through streets breaking traffic laws to better his time are suing. There are countless You Tube videos posted by cyclists of them racing through city streets, endangering themselves and others in pursuit of speed records, and their own personal X games and reality shows. A subculture in cycling supported by blogs, web pages, and tweets makes the streets all the more dangerous and deadly for pedestrians. There is no enforcement of traffic laws on MA cyclists to counteract such harmful behaviors.

    Generally, government promotion of cycling by making driving more miserable may yield more harm than good. Is more traffic congestion, road rage, and stress for 99% of road users more healthy for an unknown number of converts to bicycling and its added exercise?

    The August 8, 2012 MBTA bus driver incident in Kenmore Square crashing the bus to avoid a parking ticket could be the bus driver stress outcome that "going postal" and shooting coworkers was for US Postal Service employees under unnecessary stress before changes were made. Like workers forced to breathe second hand cigarette smoke, MBTA drivers are forced to endure added driving stress when cities impose road changes to "traffic calm" them or make them more "livable" or "sustainable".

     

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