Problem-Solving Gameplay for Mental Health

Breast cancer is the most frequently diagnosed cancer in women. Advancement in early detection and treatment over time has led to more people living with breast cancer than ever before (i.e., survivors). While we have certainly come a long way in treating breast cancer on the physical side of things, there is much work to be done in terms of how we help survivors cope with the radical change to their life after diagnosis. 

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Barriers to mental health treatment. While a significant proportion of cancer survivors report a need for professional support in managing psychological and social problems (i.e., psychosocial stressors) after diagnosis and treatment, a concerning number of patients do not receive adequate treatment. The “treatment gap” for breast cancer survivors and other vulnerable populations in the United States is largely due to barriers encountered at multiple levels: patient, provider, practice/delivery system, health plan, purchaser, and population/policy (for a review, see Pincus et al., 2003). 

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Gameplay as a possible solution to the treatment barrier problem. Several self-help therapies have been offered as a way to bypass barriers related to cost, travel burden, mental health workforce limitations, and stigma. However, many of these self-help interventions have been associated with a host of problems such as high attrition, low levels of program adherence, and low user engagement. In an effort to address some of these issues, several interventions have been designed to incorporate gameplay aimed at enhancing coping skills and improving troubling symptoms.

The results have been quite promising. As a fairly recent example, check out this 2020 randomized controlled trial by Litvin and colleagues. This study team transformed intervention content into a game with several familiar features (e.g.,  levels for passing, points). 358 participants were assigned to one of three possible study groups: (1) gamified intervention app, (2) normal intervention app, (3) waitlisted with no app. Impressively, measures of anxiety and resilience were significantly better in the game group compared to the other groups after 5 weeks. Further, the game group was able to retain a whooping 21% more participants than the other study groups!

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In the spirit of gamification, I was interested understanding (1) how receptive would primary care patients be to the idea of mental health treatment as a game oriented around problem-solving? and (2) would a problem-solving game specifically crafted for breast cancer patients be viable? 

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Why design mental health games around problem-solving? The underlying assumption here is that troubling symptoms and loss of function related to psychopathology (e.g., major depression) can often be understood as the negative consequences of ineffective or maladaptive coping with life problems/stressors. Human life is full of challenges, but these challenges can be overwhelming at times and if we are not properly equipped to deal with them, concerning physical and mental symptoms can manifest.

As it turns out, there is an entire evidence-based cognitive-behavioral therapy based on this idea: Problem-Solving Therapy (PST). PST seeks to help people adopt a realistically optimistic view of coping, better understand the role of their emotions, and creatively develop plans to reduce their distress and improve well-being. If you're curious about learning more about PST, I recommend checking out Nezu, Nezu & D'Zurilla's (2007) popular book, "Solving Life's Problems: A 5-Step Guide to Enhanced Well-Being." While PST had a strong history of success across several different medical populations, at the time I first started thinking about this project, PST had never been adapted into game form for cancer survivors. 

To better understand the interest level in problem-solving gameplay for mental health across the general patient population, my team and I designed and administered a large cross-sectional survey across our primary care clinics at Penn State. With the help of our outstanding clinic staff, we were able to have 467 primary care patients anonymously complete the survey while hanging out for their appointment in the waiting room. Respondents provided demographic and health-related information across a variety of domains, and also indicated their interest in using two types of group programs for mental health (group gameplay vs. conventional therapy delivered by a clinician).

A significantly greater percentage (23.7%) of patients expressed interest in a gameplay-based program compared to the conventional therapy option (17.6%) (p < .001). Notably, lonely patients and younger patients were more likely to report interest in gameplay. Overall, the results suggested that diverse patient populations were interested in utilizing gameplay programs as a form of mental health treatment.

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To learn more about the study, check out our publication (2018) (Download PDF) in Preventing Chronic Disease. 

Having learned that the general medical population may be interested in problem-solving gameplay for mental health, I then pulled together a research team with expertise in general medicine, psychiatry, and breast cancer oncology. Based on my literature review and expert team input, I pieced together a skeletal framework for a problem-solving game for BC survivors which would be refined over time through additional testing with patients at Penn State. 

Game overview. The gameplay concept was loosely based on non-competitive, conversational games such as Table Topics. The overall goal was to get BC patients together to practice key skills promoted in Problem-Solving Therapy (PST) across common domains of stress (e.g., family conflict, physical changes, financial struggles) identified in the research literature and through expert feedback. Teaching valuable coping skills through enjoyable gameplay offers exciting potential to increase user engagement, enjoyment, and learning, hopefully contributing to reduced distress over time.

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Wireframe 

A skeletal framework for the gameplay deck is pictured below (click image to expand) -- generally speaking, players would be presented with (1) a common scenario/problem experienced by BC survivors, and (2) a prompt that instructs them to practice a specific PST skill.  

Following our early feedback from patients and study team, we created a prototype card set for further testing. A sample card is included below (click image to expand). 

While participants appeared to really enjoy the concept and gameplay based on quantitative and qualitative feedback, recruitment of a sufficient number of patients to truly refine and iterate on the game design proved to be a major challenge on a frankly non-existent budget. As a consequence, this promising work is put on hold until additional funding becomes available.