Video Games in Psychotherapy 2022003917, 2022003918, 9781032119151, 9781032119175, 9781003222132

Citation preview

Video Games in Psychotherapy

Video Games in Psychotherapy provides the reader with a practical session-by-session framework for using video games, interactive media, and gaming metaphors to help make the process of psychotherapy more engaging for today’s youth. Using concepts from narrative, collaborative, cognitive behavioral, and other evidenced-based approaches to psychotherapy, the book gives examples of possible therapist questions, responses, and activities involving language and concepts that are appealing to young gamers. Addressing issues with psychophysiological self-regulation, anxiety disorders, and autism spectrum disorders, among others, this book uses multiple case examples to demonstrate each idea and is written in a way that is understandable for all mental health providers, regardless of their own familiarity with gaming. A review of over 40 popular video games with specifc ideas for their use in psychotherapy is provided, allowing mental health providers to easily individualize therapy based on client goals and gaming preferences. Concepts for individual and group psychotherapy using games and interactive media, ranging from Pac-Man to virtual reality, are also covered. Providing the reader with useful templates, worksheets, and other therapy resources, this book is a must-have for mental health providers working with children, adolescents, and transition-age youth. Dr. Rice is an associate professor at St. John Fisher College in Rochester, New York, and co-founder of MindFit Mental Health, specializing in integrating video games and interactive media into psychotherapy for young people.

“In his new book, Video Games in Psychotherapy, Dr. Rice has created the sweet spot every clinician craves when endeavoring to try a new therapeutic approach. He has not only efectively described the theory and research informing a videogame approach to therapy but has ingeniously translated them into clinical practice in an easy to understand and practical way. The reader quickly sees how videogames and interactive media can act as a bridge to understanding the mental health challenges and emotional needs of youth. And more importantly, how they allow the therapist to collaborate on developing a plan of care using language, meanings, and actions that are familiar to the young client. Dr. Rice provides the practical tools necessary when embarking on a new therapeutic course of action and includes case examples that bring alive the information and guidance he shares. By the end of this read, the non-gamer clinician will feel emboldened to try this innovative virtual way of engaging, understanding and empowering young people to help them overcome their mental health challenges.” Mary Tantillo, Ph.D., author of Understanding Teen Eating Disorders: Warning Signs, Treatment Options, and Stories of Courage “Although there are too many ‘how to’ books on the market today, there are very few that balance theory and practice coherently. This book provides both a contemporary theoretical foundation based in a narrative understanding of human behavior (as old as cave drawings) and specifc techniques to match the interests of today’s youth and facilitate change. Any practicing child/family therapist knows that video gaming is the predominant, sometimes obsessive, focus of today’s youth. This book provides a coherent and meaningful integration of theory and therapeutic action via generous case studies which makes it indispensable for frontline therapists working with youth. Fortunately for the reader, Dr. Rice is a natural born story teller, so his writing is engaging and digestible – just the way video games are to youth.” Gene McCabe, Psy.D. “I frst met Dr. Rice over a decade ago, when he dropped by RIT to look for potential mentors in the design and production of video games and the feld of ‘serious games.’ This book shows Dr. Rice to be a leader in the therapeutic use of video games as a common ground, and rich feld of metaphors to be mined, in therapy for youth and young adults. By using the tropes, stories, challenges and rewards experienced by the characters in video games, Rice’s approach truly makes them avatars for the players, his clients. A clinician following Rice’s approach doesn’t have to be a scholar of video games to use these methods efectively.” Professor Stephen Jacobs, School of Interactive Games and Media, Rochester Institute of Technology. Scholar-in-Residence, The Strong National Museum of Play “The chapter on how to use videogames in therapy with individuals with ASD is clever, practical and should be required reading for behavioral health clinicians who work with youth with ASD! The marriage of “music therapy” with conventional therapy by thinking with a client about the music in the video game is a stroke of genius! Dr. Rice cleverly weaves understanding of autism and the relationship of youth with ASD and their gaming to create a rich array of therapeutic strategies that are novel, efective, and based in our current understanding of neuroscience.” Susan L Hyman, MD. Professor of Pediatrics, Division of Developmental and Behavioral Pediatrics, Golisano Children’s Hospital, University of Rochester

Video Games in Psychotherapy

Robert Rice, Ph.D.

Cover Image: Getty Images First published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 Robert Rice The right of Robert Rice to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. The purchase of this copyright material confers the right on the purchasing institution to photocopy pages which bear the photocopy icon and copyright line at the bottom of the page. No other parts of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Rice, Robert (Psychologist), author. Title: Video games in psychotherapy / Robert Rice. Description: New York, NY : Routledge, 2023. | Includes bibliographical references and index. | Identifiers: LCCN 2022003917 (print) | LCCN 2022003918 (ebook) | ISBN 9781032119151 (paperback) | ISBN 9781032119175 (hardback) | ISBN 9781003222132 (ebook) Subjects: LCSH: Video games—Psychological aspects. | Video games—Therapeutic use. | Psychotherapy. Classification: LCC GV1469.34.P79 R53 2023 (print) | LCC GV1469.34.P79 (ebook) | DDC 794.801/9—dc23/eng/20220321 LC record available at https://lccn.loc.gov/2022003917 LC ebook record available at https://lccn.loc.gov/2022003918 ISBN: 978-1-032-11917-5 (hbk) ISBN: 978-1-032-11915-1 (pbk) ISBN: 978-1-003-22213-2 (ebk) DOI: 10.4324/9781003222132 Typeset in New Baskerville by Apex CoVantage, LLC

Contents

Preface Acknowledgments

xi xvi

1

Why Video Games? Why Use Video Games in Psychotherapy? 3 Side-by-Side Psychotherapy 5 One Psychotherapist’s Video Game Journey 6 Common Questions and Their Answers 8 Summary 10

2

An Integrated Approach to Gaming in Psychotherapy Narrative Therapy 13 Cognitive Behavior Therapy 13 Mindfulness 13 Who May Beneft From This Approach? 14 Who Is Qualifed to Use This Guide? 15 What Equipment Is Needed? 15 Possible Session-by-Session Outline (Based on 60-Minute Session Length) 16 Summary 19 Therapist Missions 20

12

3

Metaphors Be With You To Externalize and “Characterize” Mental Illness 21 The Termites and the Mooing Men 22 The Claws 23 To Organize and Remember Strengths and Skills 24 Power Cards 26

21

3

vi

Contents

To Better Understand the Relationship Between the Client and the Problem 28 For Social Learning 29 Jimmy the Creeper Gets Mad (by Sam) 31 Putting It Together: Video Game–Themed Treatment Planning 33 Ned’s Video Game–Themed Treatment Plan 34 Common Questions and Answers 35 Therapist Missions 36 4

Using Video Games for Self-Regulation Training Biofeedback Basics 38 The Case of Sam 40 Sam’s Video Game–Themed Treatment Plan 40 Pairing Video Games With Biofeedback 42 Choosing a Game 42 Establishing the Rules 43 Enforcing the Rules 43 Increasing the Difculty 44 Teaching Calibration With Video Games 44 The Case of Dean 45 My Self-Control Game 47 Conclusion 48 Common Questions and Answers 48 Therapist Missions 50

38

5

Using Video Games for Anxiety Disorders The Case of Alan 52 Alan’s Video Game–Themed Treatment Plan 54 Using Avatars to Diagnose and Understand a Person’s Relationship With Anxiety 55 Video Game–Themed Exposure and Response Prevention 56 A Sample of Alan’s Video Game–Themed ERP Plan (Nine Levels Total) 57 Up and Down the Worry Hill—Gamer Style 58 Video Game Imagery to Help Medicine Work Better 60 Common Questions and Answers 62 Therapist Missions 64

52

Contents

vii

6

Autism and Video Games (and Anime) Research on ASD and Gaming 66 Gaming in Therapy for ASD 67 Video Game Music 68 The Case of Dean 68 Gamifying Non-Preferred Activities 70 Dean’s Video Game–Themed Treatment Plan 71 Video Game Controller Imagery 72 The Case of Nick 72 Nick’s Controller 73 Using Avatars to Diagnose and Understand a Person’s Relationship With Autism 74 Anime and the Case of Cassy 74 Common Questions and Answers 77 Therapist Missions 78

66

7

Gamer Groups Why Gamer Group? 80 Video Games in Social Skills Groups 81 Video Games in Support Groups 82 Video Games in Psychotherapy Groups 83 One Approach to Gamer Groups 84 The Curriculum 85 Results, Discussion, and Future Directions 89 Common Questions and Answers 90 Therapist Missions 91

80

8

YouTube and Let’s Plays in Psychotherapy YouTube Videos in Mental Health 93 What Is a Let’s Play, and Why Are All My Clients Watching Them? 94 The Case of Abe 95 Let’s Plays in Psychotherapy: One Approach 96 Conclusions, Limitations, and Opportunities for Future Research 100 Common Questions and Answers 102 Therapist Missions 104

93

viii

9

Contents

Serious Games and Games for Health What Are Serious Games and Games for Health? 105 Examples of Serious Games for Mental Health 105 MindGamers and Interprofessional Design 107 Designing Mental Health Games; Learning from MindGamers 108 Crossing the Language Barriers 109 Defning Design 109 Setting Process and Scope 110 Conclusions and Future Study 111 Repetition Rebellion and Other Apps Designed to Help in Psychotherapy 112 There’s an App for That! 115 Common Questions and Answers 116 Therapist Missions 118

105

10 Virtual Reality in Psychotherapy Defning XR, VR, and AR 120 Extended Reality 120 Virtual Reality 120 Augmented Reality 120 Applications and Evidence for VR in Psychotherapy 121 VR for Exposure Therapy 123 The Case of Alan 124 VR to Teach Meditation and Mindfulness 125 The Case of Jack 125 Guided Imagery and VR: An Example 126 Forest Scene 127 Beach Scene 128 Virtual Sessions 130 The Case of Jonny 130 Common Questions and Answers 132 Therapist Missions 133

120

11 Avoiding Nature Defcit Disorder Nature Defcit Disorder Defned 135 The Argument for Nature 136 Exercise, Activity, Anxiety, and ADHD 137 Gaming’s Impact on Young People’s Exposure to Nature 137 Technology in Nature 138

135

Contents

ix

Pokémon Go 138 Geocaching 139 Real-Life Minecraft 139 Role Play 139 Among Us 140 Outdoor Local Play on Portable Devices 141 Zombies, Run! 142 Nature-Based Video Games 142 The Case of Mick 143 Common Questions and Answers 144 Therapist Missions 145 PART TWO

Video Game Directory With Ideas for Use in Psychotherapy Values Clarifcation 149 Process Used to Select the Games 150 Understanding Video Game Ratings 150 More Ways to Use This Game Directory 150 Video Games in Psychotherapy Directory 153 Among Us 153 Angry Birds 154 Animal Crossing: New Horizons 155 Astroneer 156 Bloons Tower Defense 157 Call of Duty 158 Crash Bandicoot 4: It’s About Time 159 Civilization VI 161 Cozy Grove 162 FIFA 163 Fortnite 164 Fruit Ninja 165 Just Dance 2021 166 League of Legends 168 Lego Series 169 Madden 170 Mario Kart 171 Minecraft 172 NBA 2k20 174

149

x

Contents

New Super Lucky’s Tale 175 Okami 176 Overcooked 177 Pac-Man 178 Pokémon Brilliant Diamond 179 Portal 2 180 Raft 182 Ratchet & Clank: Rift Apart 183 Rock Band 184 Rocket League 185 Sea of Thieves 186 Spiritfarer 187 Star Wars: The Old Republic 188 Stardew Valley 189 Super Mario Bros. 191 Super Mario Galaxy 192 Super Mario Party 193 Super Mario Sunshine 194 Super Smash Bros. 195 Terraria 196 The Artful Escape 197 The Legend of Zelda: Breath of the Wild 198 The Sims 199 Appendix 1 Initial Evaluation With Gamifed Language (Part 1) Appendix 2 Initial Evaluation (Part 2) Appendix 3 My Game Design Document (Therapy Plan) Appendix 4 My Stress-Control Game (Instructions) Appendix 5 My Stress-Control Game (Game Board) Appendix 6 Additional Virtual Reality Guided Imagery Scripts Appendix 7 Video Game Controller Imagery Worksheet (Xbox Version) Appendix 8 Video Game Controller Imagery Worksheet (Switch Version) Appendix 9 Video Game Controller Imagery Worksheet (PlayStation Version) Appendix 10 Video Game–Themed Treatment Plan Template Appendix 11 Video Game Therapy Ideas Worksheet Appendix 12 Tips for Parents of Gamers Appendix 13 Let’s Play Refection Worksheet Index

201 202 203 204 206 207 210 211 212 213 214 215 217 218

Preface

Let’s get this out of the way right of the bat—I am not a gamer. Sure, like every other child my age I had the original Nintendo Entertainment System at the top of my Christmas list in 1986. I immediately called all my friends in the neighborhood after opening that beautiful gray console on Christmas morning. They had all gotten one under their trees too. The next two years of our lives were dominated by this amazing plastic portal into a new world of creatures, adventures, and competition. The Legend of Zelda was my favorite game because it met both my needs for long and short-term gratifcation. Mike Tyson’s Punch-Out!! connected with me at a personal level because I always felt like an underdog. I probably played my original NES for about 94 hours straight before fnally allowing the old tube TV on which it was attached to cool down. I became less interested in video games over time, but their infuence persisted. It is amazing how the songs alone bring my mind to a nostalgic and comfortable place. I am not a gamer, but I see many gamers in therapy and appreciate their value in supporting the positive narrative for an anxious underdog with big goals and dreams. This book provides practical and accessible ideas for integrating video games and other forms of interactive media in psychotherapy for the non-gaming mental health practitioner who is tired of waiting for their clients to stop talking about video games so that they can do “real therapy.” The frst time my mind opened to video games in psychotherapy was in the early 2000s, when I  was working as the clinical director for a moderate-sized diagnostic and treatment center for people with both developmental disabilities and mental illness. I carried a small caseload of mostly young adults with autism spectrum disorder, OCD, and/or other diagnoses characterized by anxiety and repetitive behaviors. Of my approximately 20 clients, at least 19 of them were preoccupied with video games, and several of them would bring in their laptops to therapy so that they could show me their favorite games and tell me about all the hours they had accumulated playing them. I had always had a cognitive behavioral approach but was recently introduced to narrative therapy

xii

Preface

by a mentor and was looking for an opportunity to use some of what I  had learned. One of the developmental pediatricians I  worked with at the diagnostic and treatment center was also a faculty member at the Rochester Institute of Technology, a local university that had a top-fve game design program in the country. I  pitched him an idea to create a video game that emulated a CBT technique used to treat OCD. The technique used the acronym RIDE as a pneumonic to remind young people with OCD to: 1) Rename the thought, 2) Insist that you are in charge, 3) Defy (or do the opposite of) OCD, and 4) Enjoy your success. It was developed by one of my dissertation advisors, Dr. Aureen PintoWagner (Pinto-Wagner, 2003). To my surprise, he took me seriously and scheduled a meeting for me with a faculty member at the game design program at RIT. My research agenda was about to take a sudden an unexpected change in direction. Our research team included myself, my developmental pediatrician colleague, and the game design professor from RIT. At the time, this was a unique and innovative interdisciplinary endeavor. Our goal was to make my idea of a video game for my young clients with OCD and/or autism a reality, and we were able to secure enough grant funding to hire game design student co-ops to help build it. The game was eventually named MindGamers in School (Jacobs et al., 2012). It was a role-playing game that was played while in a therapy appointment and took place in a three-dimensional middle school environment that could be populated with some of the most common triggers for anxiety among mine and my colleague’s clients/patients (e.g., germs and flth, asymmetry, crowding/loud noises, uncomfortable social interactions). There was a substantial character customization process that involved creating three characters representing 1) the client (avatar), 2) the problem (problembased imp), and 3) a super version of the client representing all of her/ his strengths (goal-based imp). The customization process alone was an excellent metaphor for what was being discussed in therapy, including 1) the client’s perceived strengths, 2) how the client saw him/herself and/ or thought others saw her/him, 3) how the client viewed the problem/ diagnosis, and 4) the client’s relationship to the problem/diagnosis. My colleague from the diagnostic and treatment center was a biofeedback expert, so the game ultimately incorporated sensors that read heart rate variability (HRV), skin conductance, peripheral skin temperature, and abdominal breathing to allow players to control their avatars in the game by keeping their stress levels low when encountering virtual triggers. For example, when a player’s avatar passed a full garbage can, the problembased imp would get in the way and everything in the game would slow down until the player lowered their biomarkers for stress, at which time the goal-based imp would power-up and fght of the problem-based imp so the avatar could move forward in the game. Pictured in Figure P.1 is a

Preface

xiii

Figure P.1 The player/client (closest) is using biofeedback to control his avatar. The problem-based imp is the smaller character on the left. The goal-based imp is the small character with a cape on the right. The non-player character in the background will ask the avatar potentially uncomfortable social questions if the middle-school environment is populated with social triggers.

screenshot from the game. The character on the blue cloud is the goalbased imp. The character on the red cloud is the problem-based imp. The graph and read out at the bottom of the screen provide a real-time view of the player’s stress level using HRV, skin conductance, peripheral skin temperature, and abdominal breathing. MindGamers in School provided me with an excellent introduction to the ins and outs of game design and helped me connect with other people around the world who were interested in harnessing the value of games to promote health and well-being. Unfortunately, the game itself was not terribly accessible (biofeedback equipment alone cost $6,000) and proved to be more of an academic project than the feld-changing therapy tool I originally envisioned it would be. It probably helped me get tenure, but it defnitely did not scratch my itch to contribute something more tangible to the feld. I wanted to create a tool that mental health practitioners would fnd useful. Our research team began the process of examining what we learned from MindGamers in School and looked at ways to make a tool that was more accessible, ideally something that could be used on a portable device, such as a phone or tablet. The result, Repetition Rebellion, is an app designed to gamify homework between therapy sessions. It is still in beta form and includes many of the same concepts as MindGamers in School. Figure P.2 is a screenshot of

xiv

Preface

Figure P.2 Dashboard for Repetition Rebellion

Repetition Rebellion depicting a mission that was created by a young client with OCD. “Captain Germ” is the name he gave to his OCD. This mission was intended to help him remember to use the RIDE technique (a CBT technique for OCD) for which he decided that he would need three tools symbolized by icons. For this client, the glove represented his learned ability to self-regulate by focusing energy in his fngertips. The fairy reminded him to remember that his fear of germs involved magical thinking. The dog reminded him to pet his dog when he felt anxious and that dogs don’t wash their paws and they are just fne.

Preface

xv

Although my original intent was to develop video games that could be used as tools in mental health treatment, I learned along the way that there is even more value in examining how existing games and interactive media can be incorporated into psychotherapy as a way to: 1) destigmatize mental illness; 2) externalize problems; 3) extrapolate strengths; 4) deconstruct and reauthor client narratives; and 5) visualize and overcome stressors, among others. This book will organize and present some of what I have learned. Whenever possible, I will give case examples, followed by practical tools that even the most technologyaverse psychotherapists can use with their gamer clients. I  am not a gamer; not any more than a therapist who uses crayons with a client in play therapy is an artist.

References Jacobs, S., Rice, R.,  & Sugarman, L. (2012, October  18–20). Creating mindGamersTM: Building communication, design and development process with clinicians, game faculty and students. In Brian Winn (Ed.), Proceedings of the meaningful play. n.p., Web.* Pinto-Wagner, A. (2003). Cognitive-behavior therapy for children and adolescents with obsessive-compulsive disorder. Brief Treatment and Crisis Intervention, 3(3), 291–306.

Acknowledgments

This book would not have been possible without the support, guidance, and direct eforts of family, friends, colleagues, and “expert consultants.” First and foremost, I want to thank my family for being patient with me during the long nights of writing and regular meetings with clients to refne ideas. Second, I need to thank Dr. Gene McCabe, a mentor, colleague, and close friend who took time away from his wood working in retirement to carefully read every word I wrote about using video games in psychotherapy with young people. Dr. McCabe, you are a one-of-akind human being who contributes mightily to everything you do (e.g., family therapy, refurbishing old bicycles for inner-city youth). Thank you to Drs. Doug Guifrida, Linda Alpert-Gillis, Mary Tantillo, and Susan Hyman for reviewing my proposal and remaining available to me for questions throughout the writing process. When I decided to write this book, I did not have to think much about who to talk to. You have each played a vital role in my career and gave me the confdence to write this book. Thank you to the hundreds of clients and “expert consultants” who contributed to this book and helped shape my ideas about using video games in psychotherapy with young people. Starting with the client described in Chapter 1 who frst sparked my thinking about the topic, and more recently with the “expert consultants” who stuck with me after therapy to assemble the information for Part 2. I have and continue to learn more from you than you could ever have learned from me. Thank you for letting me (and this book) be part of your journey. I am fortunate to be in an academic environment at St. John Fisher College that allowed me to take a sabbatical to write this book. Being in academia also provided access to brilliant graduate-level interns with an interest in and knowledge of modern video games and their potential applications in mental health counseling. Specifcally, Danielle Ingrassio (class of 2015) helped with Chapter 7 on gamer groups, Shantel Giles (class of 2018) and Rachel Steiner (class of 2019) played an integral role in editing and gathering the information for Chapter 8 on Let’s Plays,

Acknowledgments

xvii

Bailey Pilant and Ellie Fichera (both class of 2021) helped with researching virtual reality applications in mental health counseling for Chapter  9, and Bryanna Gatto (class of 2021) led weekly groups with clients and expert consultants to gather the information needed to write Part 2. Noah Jacobs and Andrew Alpert-Gillis are two expert consultants who worked with the graduate interns the most, even writing letters to YouTubers to locate content with mental health themes. Alexis Call (class of 2022) also helped gather information and consider ways to use some of the video games reviewed in Part 2. Chapter 9 was also made possible thanks to the learning and opportunities provided to me through my fve-year research collaboration with Isai Pochtar, founder of XR Realms, a virtual reality (VR) software company working to make VR technology accessible to health care providers by creating intuitive and efective VR environments to practice skills like mindfulness. Isai cold called me because he had heard from others about what I was doing with video games and psychotherapy with young people. Since then, we have worked on several VR environments for therapeutic purposes, including the forest and beach environments described in this book. These environments, along with scripts for guided meditation and mindfulness practice, are currently being used to help cancer patients manage pain associated with their treatment. Chapter 10, covering games for health and game design, was informed by my decade-plus working with Dr. Laurence Sugarman and Steve Jacobs through the Health Technology and Game Design Programs at the Rochester Institute of Technology. Starting with MindGamers in School, I  have learned much of what I  know about game design from Steve Jacobs. Likewise, I would have never been introduced to biofeedback and other concepts in psychophysiological self-regulation if it were not for the enthusiasm and time spent with Laurence Sugarman. Dr. Sugarman also played a large role in designing the biofeedback board game (My Self-Regulation Game) described in this book. Finally, I need to thank my Friday morning peer supervision group. Drs. McCabe, Williams, and LeRoux have been mentors to me throughout the writing process. They helped me build the confdence necessary to share my ideas and stories, both through this book and other ways of “sharpening my tools.” I am forever grateful to be surrounded by such wisdom.

Chapter 1

Why Video Games?

Why Use Video Games in Psychotherapy? With the arrival of new contributions in the world of technology has come new applications in the health care feld. Over the last few decades, technology has fourished, and health care practitioners worldwide have noted the many benefts. With the creation of the internet, smartphones, and the various applications available to most modern multimedia devices, it makes perfect sense that these are being applied in the discovery of new treatment modalities. Advancements in technology have allowed practitioners to manage their client’s needs with greater ease. Coinciding with this is the beneft practitioners have gained in their ability to track patient progress, improve treatment outcomes, decrease length of stay in treatment, and develop newer technology-based “smart” treatment interventions. One of the most infuential and rapidly progressing technologies for young people are video games. Surveys dating back a decade have revealed that 97% of American teens between 12 and 17  years of age play video games (Lenhart et  al., 2008, as cited in Ceranoglu, 2010). Whatever one’s stance, there is an undeniable connection between video games, social media, and our current society. Video games have been used extensively across health disciplines, including for psychoeducation in chronic disease management (e.g., diabetes, asthma, sickle cell anemia (Yoon & Godwin, 2007); physical therapy and rehabilitation following traumatic brain injury (Jannink et al., 2008); and as a therapeutic tool for cognitive behavioral therapy (CBT) in clients with bulimia nervosa (Fernandez-Aranda et al., 2015)). The infuence of video games and related media on young people remains an important area of research in psychotherapy, which has shown the potential benefts of involving video games in children’s lives to help them fourish (e.g., Franco, 2016). Games hold a broad appeal that crosses generations, genders, sexualities, races, and national borders DOI: 10.4324/9781003222132-1

4

Why Video Games?

(Shaw, 2010). Scholarly work has shown video games as productive vehicles for the development of creativity, critical thinking, problem solving, and collaborative skills (Gee & Gee, 2017). The productive uses of video games have “challenged the video game’s reputation as a mindless diversion and have instead shown that they encourage thinking and learning; they play an important role in the production of cultural capital amongst young people” (Burwell & Miller, 2016, p. 111). Psychotherapy relies on the development of a working relationship between the patient/client and the mental health provider. Video games can aid in this process. The use of video games in mental health counseling can help build a connection, promote client comfort, and become a form of psychoeducation (Dini, 2012). Video games can facilitate therapeutic relationships by allowing the mental health provider to meet children where they are at. According to Ceranoglu (2010), “sitting together in front of a console and screen may facilitate a relationship and allow a safe path for a patient’s confict to emerge” (p. 144). Diagnostically, the way a child plays video games and uses them in psychotherapy can yield important clues to mental processes (Ceranoglu, 2010). By carefully observing video game play, the mental health provider can gain insight into a child’s inner world. Observation can lead to a stronger therapeutic relationship, allowing the client to share emotional themes. Some considerations include the content of the video, attitudes toward gaming, and access to video games (Ceranoglu, 2010). The emotional and intellectual connections that people can make in video games have the potential for therapeutic implications (Franco, 2016). Clients can learn therapeutic concepts that have social content and externally defned goals. Despite some resistance by the mental health community, research supports video games in psychotherapy (LaFleur et  al., 2018). They have become a part of everyday lives; we can access them easily on cell phones, tablets, computers, and gaming systems. LaFleur et al. (2018) explored how video gaming is a subculture. They proposed that being a well-rounded mental health provider includes the willingness to explore ways in which we can relate. The use of video games in therapy can bring familiarity to clients in an unfamiliar setting such as therapy (LaFleur et al., 2018). Video games can ofer a powerful tool for the therapeutic process, just as the sand tray does in play therapy with younger children. The use of video games can allow clients to explore and express themselves without any boundaries or limitations. Mental health providers can observe and discuss gaming with clients to gain insight into complex issues and the way clients process their realities (LaFleur et al., 2018). By sharing interest and understanding of the game with the client, the mental health provider is gaining permission to step into the client’s life.

Why Video Games?

5

More research relating to the use of video games to treat specifc disorders (e.g., anxiety, autism, OCD), in specifc settings (e.g., groups, outdoors), using specifc equipment (e.g., biofeedback, virtual reality, nature), and for specifc purposes (e.g., as metaphors for strengths and problems, to teach skills in psychophysiological self-regulation) is provided in each chapter of this book in order to ensure that the therapeutic strategies remain grounded in current evidence-based methods. What makes this book unique is that it also provides rich examples and ideas for how to interpret the research.

Side-by-Side Psychotherapy Have you ever gone on a road trip with a close friend? How was the conversation? Why is it that we have such rich conversations when driving or walking with someone we trust and respect? Mental health providers have been taking advantage of the benefts of side-by-side communication for years. I  was taught in my graduate training that I should angle my chairs slightly so that my clients have an “out” and do not need to look me directly in the face if they do not want to. Among the many benefts of using video games in psychotherapy with young people is the simple act of creating opportunities for side-byside conversations. Walk and talk therapy is a contemporary trend in psychotherapy that leverages the benefts of side-by-side conversations and physical activity (both elements of playing video games with clients). It is counseling in motion and tends to be more dynamic than a traditional psychotherapy session. Being physically or mentally stimulated helps release some tensions and stimulates new thoughts and ideas while keeping us out of the default mode network (not in the moment). Facing forward (sideby-side) is a metaphor for moving forward and increases many young people’s comfort level in psychotherapy—eliminating feelings of competition and/or being interrogated. Revell and McLeod (2016) examined the experiences of therapists who integrated walk and talk into their professional practice. The mental health providers involved in the study found that side-by-side conversations helped shift “stuckness” in clients, facilitated psychological processing, and promoted a more collaborative way of doing psychotherapy. Hindering factors included working with uncertainty, issues around maintaining boundaries, and the requirement to develop new skills. It is reasonable to posit that playing video games with clients can achieve the same benefts. The ideas in this book are intended to help mental health providers overcome some of the hindering factors that are experienced when starting to use video games in psychotherapy for young people.

6

Why Video Games?

One Psychotherapist’s Video Game Journey I discussed how and why I started using video games in psychotherapy with young people in the preface. My journey from there was less straightforward. After several years of learning game design and supervising student co-ops in the development of games for health, I became frustrated with the rate at which academia worked to create practical and accessible tools and began speaking more with my clients about their own gaming habits. From these conversations I learned new and hopefully more efective ways to: 1) de-stigmatize mental illness, 2) externalize problems, 3) extrapolate strengths, 4) deconstruct and reauthor client narratives, and 5) visualize and overcome stressors, among others. One client story in particular comes to mind when I  consider who infuenced my journey toward using video games in psychotherapy with young people. The client, a 13-year-old male named Aaron who was diagnosed with anxiety and ADHD (he also had many traits consistent with ASD) was referred to me to treat anxiety related to going to public places. Aaron was uncomfortable seeing anyone related to school (e.g., teachers, classmates) at places other than school. He reported feeling panic-like symptoms when this happened and demanded to be taken home. Aaron had been forced to see me by his parents, who were struggling to convince him to go places with them (e.g., the grocery store, the gym, out to dinner). Like many of the clients I had seen to that point, he had little interest in talking about his anxiety and did not understand why it was a problem that he just wanted to stay home and play video games. He made it clear that we were all lucky that he agreed to see me and not to expect that he will always be so cooperative. After trying to join with him for about half an hour, the time left in our appointment was dwindling, and I felt the urge to scramble for a way to connect. “Would you come back if we played video games?” I asked. Aaron pondered the unexpected question and begrudgingly replied, “I guess, but you need to promise me that I won’t see anyone from school and that you won’t talk to anyone from my school.” I assured him that he could make a discrete entrance and exit and that everything he told me would stay confdential as long as I was not worried about his safety. Unfortunately, in my haste to connect with Aaron, I had forgotten that I did not have any gaming equipment in my ofce and had no way to follow through on my ofer to play video games with him at our next appointment. “What video games did I enjoy when I was younger?” I thought. The answer to this question combined with my debilitating student loans led me to EBay. After scrambling to secure a used Nintendo Game Boy on EBay, I  began preparing for my next session with Aaron. What would I  do? I had not played video games since I was a kid! Maybe I could get good enough by the time I saw him again? Who was I kidding? I was working full time as the clinical director for a clinic serving people with mental illness and developmental disabilities and had young kids of my own that

Why Video Games?

7

were not old enough yet to play with me. Maybe Aaron would talk to me while he played a one-player game? Would it be ok for me to interrupt him? Ugh! Why did I agree to bring video games to the ofce! After considering my options, I decided that the only way that I could make playing video games in therapy work was if I somehow went into the session with a strategy informed by the principles I  had learned about play therapy. “Maybe this could be some sort of developmentally appropriate form of play therapy for a 13-year-old,” I thought. For it to work, I would need to demonstrate some of the skills I had learned in play therapy, such as tracking behaviors, refecting content, and refecting feeling. That way I  could at least keep my integrity as a therapist while letting my client play video games in session. When Aaron came back for his second appointment the following week, I was ready for him with the used Game Boy that I had purchased and borrowed copies of various Mario-themed games. “What the hell is that?” said Aaron. “Is this a joke?” I quickly realized that my choices in consoles and games were less than preferred. I used to love Super Mario Brothers! It turned out that Aaron was a strict PC gamer and found any consoles (e.g., PlayStation, Nintendo, Xbox) to be beneath him. Our second appointment was dominated by an in-depth discussion of the differences between PC gaming and console gaming. I could not get him to stop talking long enough for me to ask him about his anxiety. “What the hell am I going to write in my note?” I thought. I wrote, “used session to build rapport” on the form that I was responsible for completing for that appointment. I knew that this was not going to fy long term. Luckily, I already had a computer and was confdent that I could successfully download and learn to play some of the games Aaron had suggested during his second session. I could not have been more wrong. How much RAM? What is RAM? Graphics card? Where does that go? I should not have waited until the day before my third session with Aaron to start asking these questions. It once again looked unlikely that I would have the gaming equipment needed to fulfll my promise to Aaron in our frst session. The relationship was doomed. Aaron would be so disappointed that he would never come back for a fourth appointment. When Aaron arrived for his third session, I explained to him that I had underestimated the technology specifcations required for my computer to run the games that he was recommending. I  told him that I  would investigate purchasing the technology, but that it might take some time. To my surprise, Aaron did not seem disappointed. “That’s ok,” he said. “Can we just talk about video games again?” “Sure,” I replied, “but can we take breaks occasionally to talk about anxiety?” Aaron reluctantly agreed. Aaron initiated the discussion by talking about one of the games he was playing at that time, Assassin’s Creed. Despite the violent themes, I remember being impressed with how well Aaron knew the characters and spoke of them as if he knew them in real life. I was equally impressed

8

Why Video Games?

with his ability to describe his strategy in the game, including his style of play. This was not Super Mario Brothers! Although we never talked about anxiety in Aaron’s third session either, we did set some goals to “behave in real-life more like he did when playing Assassin’s Creed.” For Aaron, this meant that he would be more aware of his surroundings and how others might be thinking about a particular situation (e.g., seeing him outside of school). Aaron even agreed to imagine himself as if he was playing a video game when he left the house as a way to “be his best self” (the self that he reported feeling like when he was playing a video game that he was good at). I eventually did purchase a gaming computer, and Aaron did teach me how to play some of his favorite games. This computer has come in handy over the years for the many PC gamers who I  see in clinical practice. If there is one thing Aaron taught me it is to always ask what platform clients prefer to play their video games on and to never underestimate the passion of a gamer when it comes to individual preferences. Fortunately, as described in the following chapters, this passion became a valuable look into a client’s feelings and beliefs about themselves and the things that constrain them from being their best self.

Common Questions and Their Answers Question Do video games cause violent behavior in young people?

Answer As a mental health professional working with young people there is not a week that goes by that I am not asked if I am concerned that violent video games cause violent behavior. I get it; it is hard to see the graphic and detailed images portrayed on some video games (e.g., Call of Duty, Grand Theft Auto) and not assume, if not hope, that the increase in violence that we are seeing in our world can be attributed, at least in part, to media such as violent video games. It makes some sense to think that a violent video game might “desensitize” young people to actual violence, but instead, the vast research in the area of violent media and violent behavior consistently fnds that while there is a correlation between violent media and violent behavior, this correlation is likely not causal; rather, young people with the propensity to be violent might be more likely to choose to consume media with violent themes (Kirsh, 2010). The frst study to investigate the long-term efects of violent video game play was Kühn et al. (2019). The researchers used a variety of standardized measures of aggression, sexist attitudes, empathy and interpersonal competencies, and impulsivity-related constructs (e.g., attention-seeking,

Why Video Games?

9

boredom proneness, and risk-taking). These measures were given before and after two months of playing either Grand Theft Auto V, a non-violent video game (The Sims 3), or no game at all on a daily basis. The results provide evidence against the negative efects of playing violent video games in adults. Research examining the long-term efects of violent video games in children and adolescents is limited. Teng et al. (2022) studied violent video game exposure and bullying in adolescents. A slight positive correlation of violent video game exposure and bullying perpetration over time was found. Interestingly, moral identity moderated the relationship between violent video game exposure and bullying perpetration. The fndings suggest implementing integrated strategies that target reducing violent video game exposure and promoting positive moral development among early adolescents in bullying intervention. More studies like this are needed to better understand the relationship between violent video game exposure and violent behavior in young people. For now, it appears that the most accurate predictor of future violent behavior continues to be past violent behavior. That is not to say that mental health providers should not be concerned about the levels of violence in video games that they choose to use with their clients and patients. Although there is not a causal relationship between violent video games and violent behavior, there is reason to believe that some images or themes in many modern video games could be upsetting for certain individuals with trauma histories, anxiety, or other forms of mental illness that can be triggered by external stimuli. I  have been involved with several projects endeavoring to gamify desensitization to certain environmental stimuli that tend to trigger post-traumatic responses. One game focused on helping veterans of the war in Iraq stands out as particularly memorable in terms of how it informed my practice using video games in psychotherapy. As part of the development team, we had several veteran consultants who identifed potential triggers in our game design. The design team decided to create a realistic driving game that would provide safe exposure to the types of triggers our veteran consultants were recommending. Specifcally, the Iraq War veteran consultants reported that large black garbage bags near the road, roadkill, and unoccupied vehicles were common triggers for anxiety when driving and disrupted functioning. They also reported that the smell of diesel fuel was a powerful trigger for many Iraq War veterans, but the design team, despite our best eforts, was not able to identify a way to replicate this. I  had no idea that such things could be upsetting to an Iraq War veteran while driving. I doubt I could have come up with one of them if asked to think about it. I share this example because it often is not obvious what types of images have the potential to trigger a client when using video games in psychotherapy. Starting with games that clients are already familiar with or spending some time describing the game to a client before playing it can help minimize the risk of providing exposure to upsetting or

10

Why Video Games?

triggering images or sounds in the games you play with your clients. Sometimes, as discussed in Chapter 5, potentially triggering images are exactly what is needed to implement exposure and response prevention or similar therapeutic techniques with a client.

Question How should I use this book?

Answer This book was written to provide mental health professionals with practical, easy-to-follow guidance on how to connect with their young gamer clients/patients. The frst three chapters cover material that is applicable to all mental health providers regardless of specialty or area of expertise. Chapters 4 and beyond look more specifcally at how to use video games with many of the more common childhood diagnoses (e.g., anxiety, autism) and specifc technologies (e.g., virtual reality, biofeedback, nature). Nonetheless, it is believed that the examples in these chapters will provide valuable insight into using video games in psychotherapy with young people, even for mental health providers who have no intent to treat those issues or purchase that equipment. Part 2 of this book was written with the direct assistance of clients and interns to provide readers with an organized directory of some of the most popular games to use in psychotherapy with young people. The games provided in Part 2 span various platforms, age groups, and diagnoses. Psychotherapy ideas are provided for each game using concepts pulled from cognitive behavior therapy, narrative therapy, and values clarifcation. To use Part 2, one can simply ask a client about favorite games and look for the game in the directory. Use the ideas provided or modify them for your own purposes. You might be surprised by how creative you can get when you have a place to start! The appendix for this book was created to provide readers with a host of worksheets, documentation forms, and other tools to make the process of using video games in psychotherapy with young people easier. Progress notes, tips for parents, game controller worksheets (to remember tools/skills learned in therapy), a biofeedback board game, and templates for using video games in psychotherapy are among the many resources available in the appendix. If you are reading this book and you think there may be a tool out there to help you implement these ideas better, look in the appendix! It is probably there!

Summary The research is emerging, and technology is moving at a quantum rate. Mental health professionals who work with young people either need to

Why Video Games?

11

become more comfortable with using and talking about technology and interactive media, including video games, or risk losing touch with the next generation of clients. Side-by-side psychotherapy using video games can help clients speak more openly and feel less stuck while promoting a more collaborative way of working. It also contributes to an efective therapeutic relationship with access to new and powerful metaphors to make meaning of client stories.

References Burwell, C.,  & Miller, T. (2016). Let’s play: Exploring literacy practices in an emerging video game paratext. E-Learning and Digital Media, 13(3–4), 109–125. Ceranoglu, T. (2010). Video games in psychotherapy. Review of General Psychology, 14(2), 141–146. Dini, K. (2012). On video games, culture, and therapy.  Psychoanalytic Inquiry, 32(5), 496–505. Fernandez-Aranda, F., Jimenez-Murcia, S., Santamaría, J., Giner-Bartolomé, C., Mestre-Bach, G., Granero, R., Sánchez, I., Agüera, Z., Moussa, M., MagnenatThalmann, N., Konstantas, D., Lam, T., Lucas, M., Nielsen, J., Lems, P., Tarrega, S., & Menchón, J. (2015). The use of video games as complementary therapeutic tool for cognitive behavioral therapy in bulimia nervosa patients. Cyberpsychology, Behavior, and Social Networking, 18(12), 744–751. Franco, G. E. (2016). Video games and therapy: A narrative review of recent publication and application to treatment. Frontiers in Psychology, 7, Article 1085. Gee, E.,  & Gee, J. P. (2017). Games as distributed teaching and learning systems. Teachers College Record, 119(12), 1–22. Jannink, M., van der Wilden, G., Navis, D., Visser, G., Gussinklo, J., & Ijzerman, M. (2008). A low-cost video game applied for training of upper extremity function in children with cerebral palsy: A pilot study. CyberPsychology & Behavior, 11(1), 27–32. Kirsh, S. (2010). Media and youth: A developmental perspective. Wiley-Blackwell. Kühn, S., Kugler, D., Schmalen, K., Weichenberger, M., Witt, C., & Gallinat, J. (2019). Does playing violent video games cause aggression? A  longitudinal intervention study. Molecular Psychiatry, 24(8), 1220–1234. LaFleur, L., Hebert, Z., & Dupuy, A. (2018). Leveling up your game: The use of video games as a therapeutic modality.  Journal of Creativity in Mental Health, 13(1), 58–67. Revell, S.,  & McLeod, J. (2016). Experiences of therapists who integrate walk and talk into their professional practice. Counselling & Psychotherapy Research, 16(1), 35–43. Shaw, A. (2010). What is video game culture? Cultural studies and game studies. Games and Culture, 5(4), 403–424. Teng, Z., Yang, C., Stomski, M., Nie, Q., & Guo, C. (2022). Violent video game exposure and bullying in early adolescence: A longitudinal study examining moderation of trait aggressiveness and moral identity. Psychology of Violence, 12(3), 149–159. Yoon, S. L., & Godwin, A. (2007). Enhancing self-management in children with sickle cell disease through playing a CD-ROM educational game: A pilot study. Pediatric Nursing, 33, 60–63, 72.

Chapter 2

An Integrated Approach to Gaming in Psychotherapy

The primary approaches to psychotherapy that infuenced the ideas in this book are narrative therapy (NT) (e.g., Madsen, 2007), cognitive behavioral therapy (CBT) (e.g., Pinto-Wagner, 2003), mindfulness (e.g., Siegel, 2020), and play therapy (object-relations and experiential) (e.g., Schaefer  & Kaduson, 2006). These approaches are often complementary and lend themselves well to working with video games because they provide structure and strategy for their use in psychotherapy. They are used in an integrated fashion in this treatment guide. NT, CBT, mindfulness, and play therapy will not be explained in detail in this book, so practitioners who are unfamiliar with these approaches may want to refresh themselves on them. Mental health practitioners using this guide are encouraged to continue to modify the techniques presented to incorporate other theoretical orientations and treat other problems. It is certainly conceivable that many of the ideas presented in this book could be easily modifed for use with substance use, family therapy, trauma, and depression, among other issues. The therapeutic process outlined in this treatment guide was frst presented as part of a six-hour workshop for graduate-level mental health clinicians in 2016 and continues to be taught as part of a class titled The Identifcation and Treatment of Childhood and Adolescent Disorders in Mental Health Counseling. It was developed in collaboration with the help of hundreds of young people and their families to help them: 1) identify and internalize strengths and resources, 2) externalize or “characterize” problems/diagnoses, 3) learn skills in selfregulation in preparation for exposure and response prevention (ERP), 4) engage in ERP, and 5) celebrate “epic wins” in life. It is important to remember that using this approach is not required for video games and video game metaphors to work in therapy. Rather, it provides one possible structure for demonstrating their value throughout the treatment process. DOI: 10.4324/9781003222132-2

An Integrated Approach to Gaming

13

Narrative Therapy Narrative therapy is a strengths-based and future-focused approach to therapy. In NT, a mental health practitioner helps clients and families examine life outside the problematic context and shed light on moments of competence (Madsen, 2007). Narrative therapy provides the perfect strategy for incorporating video games in psychotherapy, as it uses techniques such as externalization to see the problem as the problem (versus the patient as the problem) and reauthoring to help clients examine their life (narrative) in unique and creative ways. The approach outlined in these pages uses NT as a framework but allows for the integration of several other theories, most notably CBT and mindfulness.

Cognitive Behavior Therapy Cognitive behavior therapy shows up throughout this book when discussing the treatment of conditions such as panic, anxiety, and obsessive-compulsive disorder (OCD). Using the video game–inspired language created through NT, CBT is used to challenge unhelpful thinking (e.g., all or nothing, obsessive-compulsive) through exposure and response prevention (ERP), cognitive restructuring, and other active approaches to confronting the externalized problem in therapy (e.g., Pinto-Wagner, 2003). Cognitive behavior therapy worksheets and treatment templates have long been a go-to tool for mental health practitioners, especially those working with children. They provide a level of perceived competence and are heavily encouraged by third-party payors. The ideas in this book take CBT worksheets and manualized approaches to a new level by providing a framework for “gamifying” them for gamer clients. When combined with the NT principles, CBT is used in a less structured and manualized way. When combined with video games and related metaphors, CBT also becomes more digestible for young clients.

Mindfulness One term that is brought up frequently in this book is mindfulness. Mindfulness is one of many ways that people engage in psychophysiological self-regulation (PSR) (e.g., Hoge et al., 2021). PSR also includes techniques such as meditation and yoga, and encompasses any way that people learn to regulate their autonomic nervous system. PSR skills training is reviewed in this book as a means to help clients fll their tool belts with strategies to confront problems, as well as routinely calibrate their autonomic nervous system. Biofeedback is one PSR tool that comes

14

An Integrated Approach to Gaming

up frequently in this book because it is easy to integrate with gaming and provides a great hook for teaching things such as conscious breathing to technology-obsessed youth (e.g., Edwards, 2016; Sugarman & Wester, 2007). Mental health practitioners are encouraged to purchase a simple biofeedback sensor (preferably heart rate variability) to get the fullest beneft from this book, especially for working with anxiety, panic, and other issues related to PSR.

Who May Benefit From This Approach? Most of the clients who helped refne the ideas in this treatment guide were between the ages of 8 and 25  years old. All were diagnosed with either anxiety, autism spectrum disorder (ASD), OCD, or issues with selfregulation. Across all the clients that benefted from and contributed to this approach, there was a wide variety of gamer styles and preferences, ranging from vintage and Nintendo to frst-person shooter games and virtual reality (VR). It is generally not necessary to adjust the approach based on a client’s gaming preferences. Asking clients about their interests and strengths upon meeting them should evoke information that will help determine whether using the ideas in this book should be a consideration. If a client reports liking video games early in the process of connecting outside the problem (joining), they are probably a good candidate. When this happens, be sure to keep asking more detailed questions like: • • • • • • • •

Are you a console or PC gamer? What are your favorite games to play? What do you like most about those games? Which video game character/hero reminds you the most of yourself? How come? What games do your friends like to play? How come? What is your best attribute as a gamer? What do you like the most about playing video games? Are video games ever a problem in your life?

Once you have determined that a client is a good candidate for this approach, you can introduce them to the idea by asking questions such as: • •

What would a video game about your life look like? What kind of game would it be? A role-playing game? A strategy game? Something else? How do you feel about using video games as a way to talk about things in here (therapy)?

An Integrated Approach to Gaming

• •

15

Would you be willing to teach me more about the video games you play? Do you think video games can help with mental health? How?

Depending on the answers you receive you will know how far to take it. Asking permission is often helpful (e.g., “Is it ok if we talk about video games as a way to talk about your life when you aren’t gaming?”).

Who Is Qualified to Use This Guide? Any licensed mental health practitioner (e.g., mental health counselor, social worker, psychologist, marriage and family therapist, play therapist, psychiatrist) is qualifed to use this treatment guide. As discussed in the preface, one need not be a gamer in order to use this book. What is needed is an open mind, curiosity, and willingness to put aside the traditional beliefs about what therapy should be. Two wise therapy sayings that ring true when considering the content of these pages are: 1) Therapy is in the mind of the therapist (Carl Whitaker), and 2) People take what they need from therapy and it usually isn’t what we think we are giving them (a wise psychologist and personal mentor).

What Equipment Is Needed? A tablet should be enough to implement most of the ideas in this book, but if you want to make this a substantial part of what you do, then investing in some additional technology can help take your therapy to another level. The equipment listed here is recommended in order of probable value for mental health practitioners doing this work (i.e., the items with a higher ranking should be purchased before the items with a lower ranking, unless specialization dictates otherwise). 1. 2.

3. 4.

Tablet (e.g., iPad, Android): approximately $200–$400 Gaming PC, controllers, and monitor (minimum specs are Windows 10; Intel Core i5–6600K @ 3.5 GHz processor; 8 GB RAM; NVIDIA GeForce GTX 1070 8GB graphics; and a 1 TB [SSD or HDD] hard drive): approximately $800–$1,200 Modern gaming console, controllers, and TV (either Nintendo Switch, Microsoft Xbox One, or Sony PlayStation 4 or 5): approximately $400–$800 Biofeedback sensor (preferably a heart rate variability [HRV] sensor; HeartMath Inner Balance is a reliable choice; the Nexus by Mind Media is a more comprehensive and expensive option): approximately $125

16

An Integrated Approach to Gaming

5.

Vintage gaming console (e.g., NES, Atari, Sega Genesis): approximately $100–$200 Virtual reality headset (e.g., Occulus Quest; Sony PlayStation VR; HTC Vive Cosmos): approximately $300–$500

6.

What equipment to purchase will also depend on one’s area of specialization. For example, mental health practitioners who work primarily with anxiety and panic will want to prioritize a biofeedback sensor over additional gaming consoles and games. Particular games are not included in this chapter because the list would be too extensive. Instead, this treatment guide includes an entire section (Part 2) dedicated to different video games that might be considered for use in therapy, along with suggestions for how to use them.

Possible Session-by-Session Outline (Based on 60-Minute Session Length) Session One Session one should focus on joining with the client and family. The session should start with an overview of what to expect (e.g., “I  am going to ask you some questions today. You can stop me and ask me any questions that you have whenever you want. After I ask you a question, I will ask your permission to ask your parents the same question. Please be sure to correct them [parents] if they get anything wrong.”) and acknowledgment that you as the mental health provider are an outsider. Once these things have been accomplished, you can proceed with the joining process by asking about a client’s interests and then strengths, using the types of questions provided earlier in this chapter. It is always possible that someone will want more time to discuss problems before spending too much time on interests and strengths, but this is generally rare. After establishing yourself as an “appreciative ally” (Madsen, 2007) to the client by listening to their interest and strengths for 30 minutes or so, it is time to ask the crystal ball question (i.e., “What will be diferent when your life is going even better than it is now?”). The wording of the crystal ball questions is important (e.g., “even better,” “when you”) because it communicates a future focus, confdence in the client to achieve that future focus, and acknowledges that life is not so bad right now either, as evidenced by the client’s previously shared interests and strengths, as well as other examples of life outside the problematic context. As with every question in the frst session, the identifed patient (IP) is asked the crystal ball question frst, followed by any parents in the room, with the IP’s permission. Careful

An Integrated Approach to Gaming

17

attention should be taken to ensure that the IP and her/his parents/ family answer the crystal ball question using positive language (e.g., “I will be more relaxed at school” instead of “I will be less anxious”). One way to do this is to say, “what will you be instead?” when a negatively phrased answer is provided. Sometimes the crystal ball question can take the rest of session one. When it does not, you can begin exploring the constraints to the future focus or “what’s getting in the way.” This is when the video game metaphors can really start becoming useful. Anxiety, OCD, anger, and issues with socialization are among the most common constraints reported for the clients who contributed to the current approach. The only goal in the frst session as it pertains to dealing with constraints/problems is to begin the externalization process (see Chapter 3 for more on how to do this with gamers). Session one typically ends with a “mission” (because missions are better than homework). For example, to use a character creator on one of the IP’s favorite video games to create an image of the main problem they are coming to therapy for. Naming the character is an important part of this process because it helps diferentiate the IP’s problem from others with the same diagnosis and helps parents unite with the IP against the problem. Session Two Session two and every session thereafter might start with the question, “Tell me one good thing that’s happened in your life since our last appointment.” The purpose of this question is to establish from the beginning of each appointment an interest in the exceptions to the problematic context and change the narrative that therapy is to talk about problems. After discussing the “good thing,” it is time to look at the character the client created for her/his mission after session one and spend some time understanding the choices and their possible meanings (again, see Chapter 3 for more on this). About halfway into session two is generally a good time to ask the IP and family about what has been tried so far to deal with the problem (which should now have a name and face). A  good rule of thumb is to continue listening to what has been tried to deal with the problem until the words, “It sounds like you tried everything” can be uttered. The purpose for this is twofold: 1) It ensures that you do not recommend something that has already been tried unsuccessfully, and 2) It shifts the IP’s perspective from a stance of no control to one that is focused on the future. Session two might end with the question “What is one thing that other people/providers don’t understand about you?” Sometimes, introducing

18

An Integrated Approach to Gaming

the concept of conscious breathing (see Chapter 4 for more on selfregulation skills training) can also be helpful at this time. When appropriate and applicable, a mission can also be assigned at this time to practice conscious breathing at home, in whatever way the IP feels comfortable. Another possible mission might be to start a gaming journal to begin establishing a baseline play rate and provide content to be explored in therapy. Session Three By now the IP should have provided enough information regarding his/her favorite and most played video games that a game can be chosen or imagined for assessment purposes. Assessment using this approach involves identifying in-game metaphors to represent reallife attributes, systems, and problems. More guidance on how to do a video game–based assessment is provided in Chapter 3. One helpful question at this time might be something such as, “What would it look like if your life were a video game and (the problem) is the big boss?” Assessing an IP’s player style/type can also be helpful around now. There are several player types and models that have been proposed in the literature, and all of them are covered well in Dr. Anthony Bean’s book Working with Video Gamers and Games in Therapy (2018). For the purpose of the current book, Fullerton’s model for understanding player types is used. Fullerton (2008) proposes ten player types that include: 1) the competitor, 2) the explorer, 3) the collector, 4) the achiever, 5) the joker, 6) the artist, 7) the director, 8) the storyteller, 9) the performer, and 10) the craftsman. Understanding a client’s player type can provide tremendous data about her/his typical way of operating in real life and/or his/her preferred way of operating if constraints were not present. Session Four It is around now that a video game–themed treatment plan can be constructed. The structure for most video games ofers a great metaphor for treatment—there are multiple levels, each level gets harder and requires new skills and tools, there is a big boss at the end who will need to be confronted, and it will feel great when the game is won. One example of a video game–themed treatment plan is provided in Table 2.1. Further guidance on how to implement this approach to treatment planning is provided in Chapter 3, including case examples showing this template in use.

An Integrated Approach to Gaming

19

Table 2.1 Template for creating a video game–themed treatment plan

Environment/ setting Main characters

Tools needed

How to earn points Level won when

Level One

Level Two

Level Three

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1 point = 2 points = 3 points =

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1 point = 2 points = 3 points =

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1 point = 2 points = 3 points =

Sessions Five and Beyond As most seasoned mental health providers know, this is where it becomes much more difcult to provide an outline because each client and her/ his treatment plan will difer greatly depending on age, goals, and diagnosis. More ideas for session plans that might be used later in therapy are provided later in this treatment guide (Chapters  4, 5, and 6) and correspond with client goals and diagnoses.

Summary While there is no one way to do therapy, many gamers appreciate and do well with an approach that leverages video game concepts and metaphors. The approach outlined in this book is inspired by narrative and cognitive behavioral therapy, as well as mindfulness and other ways for teaching skills in psychophysiological self-regulation. It provides a fexible and easy-to-follow framework for working with gamer clients, regardless of one’s profciency in gaming. Clients who identify as serious gamers are likely to beneft from this approach, which was developed with the help of hundreds of children, adolescents, and transition-age youth with autism spectrum disorder, OCD, anxiety, and/or issues with self-regulation. This approach could also be easily modifed for use with other populations. To implement this approach as a regular part of one’s practice, it will be necessary to purchase some technology, but a tablet alone is enough to implement most of the ideas ofered. When using this

20

An Integrated Approach to Gaming

approach, the frst fve sessions tend to follow a similar format, but things can vary greatly after that depending on the client’s age, diagnosis, and goals.

Therapist Missions • •

• •

If necessary, refresh yourself on narrative therapy. Collaborative Family Therapy with Multi-stressed Families (Madsen, 2007) is an excellent resource for doing this. If necessary and if the intention is to implement the approach outlined in this treatment guide with people with anxiety, OCD, panic, and/or other issues related to psychophysiological self-regulation, refresh yourself on CBT, mindfulness, conscious breathing, and/or other approaches for helping people overcome anxiety and anxiety disorders. Determine the extent to which this approach will be utilized and the technology required to do so efectively. Begin asking clients about their gaming habits, including their favorite games and player style.

References Bean, A. M. (2018). Working with video gamers and games in therapy: A clinician’s guide. Routledge. Edwards, L. (2016). Combining biofeedback and mindfulness in education. Biofeedback, 44(3), 126–129. Fullerton, T. (2008). Game Design Workshop: A playcentric approach to creating innovative games. Morgan Kaufmann. Hoge, E., Acabchuk, R., Kimmel, H., Moitra, E., Britton, W., Dumais, T., Ferrer, R., Lazar, S., Vago, D., Lipsky, J., Schuman-Olivier, Z., Cheaito, A., Sager, L., Peters, S., Rahrig, H., Acero, P., Scharf, J., Loucks, E., & Fulwiler, C. (2021). Emotion-related constructs engaged by mindfulness-based interventions: A systematic review and meta-analysis. Mindfulness, 12(5), 1041–1062. Madsen, W. (2007). Collaborative therapy with multi-stressed families. Guilford Press. Pinto-Wagner, A. (2003). Cognitive-behavior therapy for children and adolescents with obsessive-compulsive disorder. Brief Treatment and Crisis Intervention, 3(3), 291–306. Schaefer, C.,  & Kaduson, H. (Eds.). (2006). Contemporary play therapy: Theory, research, and practice. The Guilford Press. Siegel, D. (2020). The developing mind: How relationships and the brain interact to shape who we (3rd ed.). The Guilford Press. Sugarman, L.,  & Wester, W. (2007). Hypnosis with children and adolescents: A contextual framework. In W. C. Wester II & L. I. Sugarman (Eds.), Therapeutic hypnosis with children and adolescents (pp. 3–24). Crown House Publishing Limited.

Chapter 3

Metaphors Be With You

One of the most useful ways to incorporate video games into psychotherapy involves using gamifed language to help understand, externalize, and deconstruct client strengths and problems. The current chapter will focus on many of the ways this might be done. This chapter can be the most helpful to those readers who have no intention of making extensive investments in technology, as most of the strategies described here can be implemented without any equipment. Often, the hardest part of doing this work is starting the conversation. Metaphors are an excellent way to communicate and understand client problems that might be difcult to explore otherwise, especially early in the therapeutic process (Zatloukal et al., 2019). One question that can be helpful in this regard is, “If your life was a video game and (the problem) was the big boss, what would that look like?” Common responses are: “Bowser” (or another big boss from a game they often play), “a creature” (including details), or confusion by the client. If the response is confusion, the following explanation is often helpful: “Life isn’t really all that diferent from a video game. We spend our time learning new skills and acquiring new tools to level up. We have boss battles too in order to get through the levels. Anxiety (or the client’s problem) can be one of these bosses.” Followed by questions such as: If the problem was a boss, would it be a mini-boss or the big boss? What would it look like? Are there any games you play that have a boss or other character that reminds you of (the problem)?

To Externalize and “Characterize” Mental Illness One of the simplest and potentially most helpful ways to incorporate video games into psychotherapy is to use them to support the process of externalization. Externalization is the process that shifts a client’s perspective of a problem from being ego-syntonic (internalized) to ego-dystonic DOI: 10.4324/9781003222132-3

22

Metaphors Be With You

(externalized). In doing this it allows the problem to be seen as separate from the client and helps families unite with the client against the problem (Madsen, 2007). In its most basic form, externalization involves referring to the problem (e.g., anxiety) as the problem (e.g., “When anxiety shows up, what is it like for you?”). When leveraging video games, externalization can become characterization by asking the client to create a character using technology and/or video game–themed language to metaphorically represent the problem being discussed. Doing this provides tremendous insight into a client’s relationship with the problem and can assist in making a diagnosis. What follows are two examples of how this might look. Additional examples are provided in later chapters discussing specifc diagnoses (e.g., Chapters 5 and 6). The Termites and the Mooing Men These characters were created by an 11-year-old client who met criteria for disruptive mood dysregulation disorder (DMDD) to describe his rage and anxiety. The client, “Sam,” was a big Minecraft fan who loved building with wood in the game. He was proud of his creations and would be crushed if they were somehow damaged. What could damage magnifcent structures made of wood? Termites of course. Naming rage the “Termites” had tremendous meaning for Sam because it communicated his belief that his aggressive outbursts at school served to break down and damage the smart kid reputation that he had worked so hard to build with his teachers. Sam’s anxiety was named the “Mooing Men” because he viewed anxiety as a distraction and barrier to doing something. In Minecraft, cows serve a similar purpose, distracting the player and getting in the way when they are not welcome. Sam described anxiety as having someone mooing loudly in his ear, disrupting his ability to think and solve problems. Sam’s use of the names Termites and Mooing Men helped provide tremendous insight into his mental status at any given time, as he had some elements of a bipolar process that was characterized by high rage when manic and high anxiety when depressed. He took Abilify to treat the Termites and Lexapro to treat the Mooing Men, so Sam’s descriptions of these characters, their relationship to each other, and impact on him provided useful information for his child psychiatrist to make decisions regarding psychopharmacological interventions. Perhaps most importantly, using these names to describe rage and anxiety made it possible for Sam’s parents to communicate to him that they were united with him against the problem. To maximize this efect, they were also instructed to look to the side of Sam when addressing the Termites or the Mooing Men. Sam reported feeling less judged and more supported once the Termites and the Mooing Men were named.

Metaphors Be With You

23

The Claws The Claws was the name given to obsessive compulsive disorder (OCD) for one of the earliest clients who “characterized” his diagnosis with me in psychotherapy. It remains one of the best examples for illustrating how this process can assist in exploring a client’s relationship with the problem or diagnosis. In this case, the Claws shed important light on whether a repetitive behavior truly followed an obsessive-compulsive process or was more typical of a preoccupation or other stereotyped behavior often seen in people with autism spectrum disorder (ASD). The client who created the Claws, “Don,” was a transition-age youth with ASD who had a fear of potentially noxious or harmful fora, especially poison ivy. Don also demonstrated several of the restrictive, repetitive patterns of behavior that are commonly attributed to ASD, so his new fear of poison ivy did not completely ft with his historical diagnostic profle. People with ASD are often dually diagnosed with OCD by clinicians looking through a mental health lens because their restrictive, repetitive behaviors do not ft well within other mental health categories in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The way a person with ASD communicates obsessions can also be diferent and more difcult to interpret by clinicians, contributing to misdiagnosis (Rice et al., 2014). One of the misconceptions about people with ASD is that they do not do well with metaphors. My experience has been the opposite, assuming the right metaphor is found. Luckily for many of my clients, fnding the right metaphor is usually not that difcult once we begin discussing their favorite video games. In Don’s case, that was any game involving zombies. When asked if the feeling he got when he was concerned about noxious fora reminded him of anything that happens in the zombie games he played, he put his head down and began to draw. In addition to being an avid gamer, Don was a cartoon artist in training who had taken several cartooning classes and even created a hand-drawn animated feature called “Dust Busters,” a spoof on Ghostbusters. It was shown at a local theater and was hilarious in a dark, “grandma dies” kind of way. Like many people with ASD, Don had tremendous artistic talent and would seemingly go into a trance when he was drawing. He would speak out loud about what he was trying to create, but not for anyone else but himself to hear. “That’s right. That line goes there.” He spoke under his breath, but loudly enough to be easily understood. By the end (about 15 minutes), he had created the Claws and was ready to describe him. The giant claws that extended from its arms (thus the name “Claws”) reminded Don of the image he gets in his mind when he thinks poison ivy might be in the area. Don reported feeling like the poison ivy would slice his skin, but on a microscopic level, allowing its toxins to infltrate

24

Metaphors Be With You

Figure 3.1 Pictured are the Claws after being defeated by Don in the video game that he was designing about his real-life battles with OCD.

his system. He feared that once his system was infltrated, it would never return to baseline and that he would forever be susceptible to fare-ups. Don further reported that the Claws did not have ears because, as many clients with OCD report, “The Claws don’t listen.” Clearly, Don was describing a process that was much more obsessive-compulsive in nature than not, leading to his ultimate diagnosis of OCD and decision to treat his fear of noxious fora with CBT (rather than ABA or trying to create structure or limits on Don’s rituals—the standard approaches for working with restrictive, repetitive behavior in ASD).

To Organize and Remember Strengths and Skills Don is also a great example of using video game metaphors to make the process of discussing strengths and skills in psychotherapy more engaging and memorable. Of course, all his ideas were inspired by zombie games, but he put his own spin on them too, extrapolating on things that he had seen in games to design tools that better ft with his noxious fora obsession, personal strengths, and skills learned in psychotherapy. Don’s artistic talents came in helpful once again in this regard. The strengths and skills discussion for Don was especially memorable. By now, a more traditional strengths assessment had already been completed, so a list of perceived strengths was already available. As usual, this conversation started with the question “If your intelligence

Metaphors Be With You

25

Figure 3.2a Don’s tools

Figure 3.2b Don’s tools

(or insert client strength here) was a tool in Zombie Nation (or insert client’s favorite video game here), what tool or weapon would it be?” The obvious answer for Don was a katana blade because it is “sharp.” Don continued to describe several other tools, all inspired by the video game Zombie Nation, that matched with the strengths and skills that might be useful in confrontations with the Claws. The “Power Wand” represented his courage and was used to contact noxious fora without being infected. The “acid bath” represented Don’s breathing skills and other

26

Metaphors Be With You

psychophysiological self-regulation skills he had learned to that point in psychotherapy. After defying the Claws in his life, Don would imagine himself dropping infected items into the acid bath. In this way it served the multiple purposes of helping him remember to use his skills, providing him with an image to help him use his skills more efectively, and providing him with a way to discuss this process in psychotherapy that was both comfortable and sometimes even fun. While all of Don’s ideas for tools to confront the Claws were pretty cool, it was the goggles that proved to be the most useful. As a person with both ASD and OCD, Don often struggled in the moment to identify and communicate an obsessive thought as illogical or unlikely. The goggles, inspired by a pair worn by one of his favorite video game zombie hunters, had a dial on the side with the settings 1) real poisons, 2) real allergens, 3) fake poisons, and 4) fake allergens. When Don was having a hard time deciding whether the anxiety he was feeling was warranted (e.g., because he ran barefoot in a feld of poison ivy) or caused by the Claws (e.g., because his mother bought pruning scissors at a garage sale that might have been in contact with poison ivy at some point in their history) he would imagine putting on his goggles and going through each of the possible options, trying to use logic to make a decision he felt comfortable with. Don put his metaphorical goggles on almost every session after they were created to help communicate his experience with obsessions experienced between appointments. Power Cards Power cards are a great way to remember strengths and skills for younger clients (around 7–12  years old). They allow for the creative and playful use of video game metaphors to strategize against problems, even when the technology to actually play video games is not readily available. There are online companies that will create professional-looking power cards for a cost (e.g., mytradingcards.com), but designing the cards on the computer using Microsoft Word also works, and printed cards can be laminated to help them last longer. Power cards can be carried with clients as a reminder of their skills and plans to confront problems or kept at the therapy ofce to discuss past “battles” and plan for future ones. For example, if a client knows the problem is likely to occur in a particular situation (e.g., before a math test), the mental health provider and client can use the power cards to think through the situation and fnd a “hand” of power cards that is most likely to secure victory. The power cards depicted in Table  3.1 were created by a nine-yearold boy with OCD, “John.” John named his OCD the “Bothers” and the “Fox.” The Bothers was the name John used to describe OCD that was annoying but not debilitating. The Fox was the character John saw as in

Metaphors Be With You

27

Table 3.1 John’s power cards Front

Back

Mind Key

How? 1. Focus on left hand fingertips or left pinky toe. 2. Use abdominal breathing. When? • When I feel uncomfortable. • When I am worried or scared about something.

Herobrine How? (Minecraft character that 1. Imagine that the Fox is the one in trouble never actually appeared in and I can make him feel this way. the game) 3. Examples include busting up his house, scaring him, etc. When? • For terribly hard Bothers. • Use with other power cards to increase their strength. Entity 303 (Another Minecraft fancreated character often referred to as “the new Herobrine”)

How? 1. Team up with Entity 303 to tell the Fox that something scary has happened, like his house is on fire, or to watch out for traps and TNT. 2. Entity 303 and Herobrine often work together. When? • When I am worried or scared about something.

Giving Bothers the Bothers How? 1. Tell the Bothers in my mind that something bad will happen to him if he doesn’t do as I command. 2. Slip past “stuck spot” while Bothers are completing ridiculous task. 3. Look back and laugh in my mind at the Bothers for his weakness. When? • Before I start something fun. • When I am bored. The John Card “I will always try my best to use my strategies. I am so proud of myself for all the hard work I put into taking control of the Fox. I am not going to let the Fox waste all the hard work me and my team did.”

28

Metaphors Be With You

control of the Bothers. The Fox was more powerful than the Bothers and did not always respond to the techniques that worked for the Bothers. John’s favorite video game was Minecraft, so metaphors from this game dominated his power cards. He also enjoyed playing Mario Kart, so he made sure to include some metaphors from that game as well. The front side of John’s power cards included a name (for the strength, skill, or technique) and image (usually borrowed from a favorite video game) that helped him remember it. The back side of each card described the strength, skill, or technique and provided guidance on when to use it. A sample of John’s power cards is provided in Table 3.1.

To Better Understand the Relationship Between the Client and the Problem Often, using video game metaphors in psychotherapy to “characterize” client problems provides valuable diagnostic information. The case example of Don’s OCD named the Claws from earlier in this chapter is a prime example of this. As with Don, many clients with OCD create a “big boss” that does not have ears because “OCD doesn’t listen.” Excessively large ears are also common for characters created to represent OCD because, “OCD hears everything.” For the mental health provider, this type of information can provide great value for understanding the client’s experience with the problem and even make a diagnosis. The extent to which a problem or diagnosis is ego-dystonic (vs. egosyntonic) is also essential to understanding a client’s relationship with it (e.g., Guzick et al., 2019; Hart et al., 2018). In many circumstances, the extent to which a client identifes with her/his mental illness can determine whether it meets criteria for a particular diagnosis in the DSM-5. For example, OCD can only be diagnosed in adults if it is ego-dystonic (i.e., the person recognizes that the obsessive thoughts are excessive and/or atypical). OCD that is ego-syntonic in adults often meets criteria for a psychotic disorder, potentially indicating a substantially diferent treatment plan. The criteria related to whether obsessions are ego-dystonic is waived for children because children are believed to possess a higher capacity for magical thinking that is still developmentally appropriate. Many of the big bosses that clients create can shed light on whether a problem or diagnosis is ego-dystonic. Generally speaking, big bosses that are less menacing or ferce looking might be considered to be more egosyntonic. Research examining the exact extent to which a big boss predicts how much a client identifes with a problem or diagnosis is not yet available, but asking questions such as “Your big boss looks like it could be friendly sometimes. Did you intend to create it that way?” can evoke the type of information that any skilled mental health provider could use to better understand the role it plays in the client’s life.

Metaphors Be With You

29

Some of my favorite examples of how big bosses can be helpful diagnostically resulted from research that my colleagues and I did for the original MindGamers in School video game that I discussed in the preface (and again in Chapter 9) for this book. In the game, players were instructed to create a “problem-based imp” representing a real-life problem, such as anxiety or OCD. Approximately 15 9–13-year-olds with various diagnoses, including ASD and OCD, participated (Jacobs et al., 2012). As a result, several of the problem-based imps created represented diferent repetitive behaviors along a spectrum, ranging from the types of preoccupations and stereotypes common in ASD to the intrusive thoughts and compulsive behavior indicative of OCD. Research suggests that repetitive behaviors in ASD are often more ego-syntonic than those in OCD, which are almost always ego-dystonic (Rice et al., 2014). In MindGamers in School, players could create problem-based imps that looked as scary or friendly as they wanted. As would be expected, the players with OCD created problem-based imps that were markedly more like monsters or creatures than did the players with ASD, who at times created characters that looked more like a rebel. One player described his problem-based imp as “like a best friend that gets me into trouble” (Rice, 2016).

For Social Learning Sam is a client who shows up a few times in this book. Sam, the young man who externalized his rage and anxiety as the Termites and the Mooing Men, respectively, went through a couple year period in late elementary school when he was being suspended on a fairly regular basis because of behavior resulting from difculties self-regulating in school, especially during competitive situations like physical education class. Following one of his suspensions, the support team at his school held a meeting to discuss Sam’s behavior and possible options to better manage it. In addition to working to help his team understand the psychophysiological basis for Sam’s behavior, the focus of this meeting ended up being about how Sam was most likely to learn from his “mistakes.” In particular, the support team was interested in how Sam could “make the most of his time while suspended.” I suggested that we try a social storybased approach (e.g., Smith et  al., 2021; Gray, 2001) using Minecraft, Sam’s favorite video game at the time. Sam really liked creepers, the green non-player characters (NPI) in Minecraft that are generally more of an annoyance in the game than anything else. This time Sam had been suspended for punching a classmate during a heated moment playing soccer in physical education class. He doubled down on the physical aggression by damaging property in the school counselor’s ofce. As was often the case, he only calmed down when he knew that his father had been called and was coming to pick him up. His rage

30

Metaphors Be With You

(the Termites) shifted to despair and anxiety (the Mooing Men) at this point because Sam knew that his father was likely to take away electronics. Sam readily accepted an assignment to write and illustrate a story about a character in Minecraft that made a mistake and learned from it. The incentive for him was that he would be able to use Minecraft during his suspension, despite being cut of from electronics. As expected, Sam decided to write a story about a creeper. He named the main character Jimmy and illustrated the entire story using Minecraft. What resulted was the frst in a series of “Jimmy the Creeper” stories that Sam used to think about and explain his behavior at school so that others could see them the way he did and respond accordingly. The frst story, “Jimmy the Creeper Gets Mad,” provided tremendous insight into Sam’s experience of rage in gym class and helped his support team at school consider better ways to work with rage when it showed up in the future. The frst scene depicted Jimmy the Creeper walking to a party. Sam wrote that Jimmy the Creeper walked through “the savanna biome, the snow biome, and the planes biome.” Herein lies the frst example of how the story provides insight into Sam’s experience. The biomes Sam chose to use in his story are widely considered by Minecraft afcionados to be among the most difcult biomes in the game. I was able to learn this by asking questions such as, “What is a biome?” and “How come you chose those biomes for this story?” When interpreted in therapy, Sam acknowledged that it “always feels hard for me to go to gym because I know that the Termites are going to be there.” Other examples of meaning in Sam’s story about Jimmy the Creeper are not difcult to fnd when considering Sam’s situation and questioning him on his experience and reasons for writing the story as he did. For example, when he wrote that “Jimmy the Creeper respawned in a new world. No friends, no food, and no family. Jimmy was sad and he cried and had no shelter either.” Sam was communicating how he felt about being suspended. Until now, the support team questioned whether Sam really even liked school. When he wrote that he did not have another opportunity to go to a similar party for ten years, he was expressing his perspective that a week’s suspension felt like an especially long time. Future additions of Jimmy the Creeper included, “Jimmy the Creeper: The Bad Sport,” “Jimmy the Creeper Has a Good Day,” and “Jimmy the Creeper Helps a Friend.” After completing each story, Sam would come to my graduate class on counseling children to read it aloud and answer questions. Sam is in high school now but continues to take pride in how he worked through his experiences with rage by writing Jimmy the Creeper stories, and that these stories may have helped future mental health counselors to help other children with their own versions of the Termites.

Metaphors Be With You

31

Jimmy the Creeper Gets Mad (by Sam)

Figure 3.4

Figure 3.5

Figure 3.6

Figure 3.7

Scene One (Figure 3.4) One day Jimmy the Creeper went to a party in the desert temple. It was a long walk through the Savana biome, the snow biome, and the planes biome. Jimmy the Creeper arrived. Scene Two (Figure 3.5) He had so much fun playing soccer (the only sport creepers can play). But then Bobby the Creeper shoved Jimmy the Creeper. Scene Three (Figure 3.6) When it was cake time only a crumb was left when Jimmy got up front. Jimmy was mad and sad, so he kicked Bobby, who fell into the freplace and tripped Jimmy, who blew Bobby up.

32

Metaphors Be With You

Scene Four (Figure 3.7) Jimmy the Creeper respawned in a new world. No friends, no food, and no family. Jimmy was sad, and he cried and had no shelter either.

Figure 3.8

Figure 3.9

Figure 3.10

Scene Five (Figure 3.8) Ten years later Jimmy was going to another party in the stronghold. When Jimmy arrived he played soccer for a while, then it was cake time. Scene Six (Figure 3.9) Morgan the Creeper shoved Jimmy the Creeper. When Jimmy the Creeper got to the front of the line there was nothing left but a crumb.

Metaphors Be With You

33

Final Scene (Figure 3.10) “Again!” thought Jimmy the Creeper. Jimmy the Creeper almost kicked Morgan the Creeper, but he remembered last time. Jimmy the Creeper had no friends, family, or shelter. So, Jimmy the Creeper told Morgan the Creeper. Morgan the Creeper felt bad and said sorry and asked if Jimmy the Creeper would like some of hers. So Jimmy said “YES!” and lived happily ever after. THE END.

Putting It Together: Video Game–Themed Treatment Planning A video game–themed treatment plan template is provided in Chapter 2 under session four for the proposed session-by-session outline. It is now time to explain how to use it. As with every idea in this book, real client examples will be used to explain what they might look like and what questions the mental health provider might ask. The following example is from a nine-year-old client with hoarding behaviors, “Ned.” When he was referred, his parents and teacher were concerned that he was not able to fnd things in his backpack because it was full of paperclips, old pencils, crumpled pieces of paper, and other small items he would fnd while at school. Ned reported that he felt anxious when he saw some things at school but did not pick them up. He reported feeling even more anxious if made to throw away things he had accumulated in his backpack. As with so many clients in this age range between 2010 and 2015, Ned loved playing Minecraft and chose to use it as inspiration for his treatment plan. To understand Ned’s treatment plan, it may be helpful to understand a little more about the process that was used to create it. First, Ned had to decide what he was working on in real life (boredom and anxiety), where he was going to work on these things (school and bedroom), who would be there (e.g., himself, teacher, parents, hoarding), what exactly he would be doing (i.e., how to earn points and win levels), and what tools he would need to do these things (i.e., his identifed strengths and skills in real life). After each of these things was decided, Ned was asked questions such as, “If your school was a biome in Minecraft, which biome would it be?” and “If your teacher was a character in Minecraft what would she be?” For Ned, the process of deciding on real-life goals was integrated with choosing video game metaphors so he stayed engaged and to maximize opportunities to explore the meaning of decisions made. Deciding on how to earn points and win levels is also an important part of the process of developing a video game–themed treatment plan. Typically, fewer points are given for easier missions or tasks, and levels are won based on consistently earning points during a particular period of time (e.g., one week, before the next psychotherapy appointment). Sometimes points are replaced with tasks completed or another method to measure

34

Metaphors Be With You

progress. Arguably, the method used to measure progress is less important than the process of collaboratively determining how progress will be measured, as it is during this conversation that the client will communicate important data regarding what is perceived as more difcult, reasonable, and what “winning” looks like. In Ned’s case, his choice to start level one at school was a surprising one since that is where he typically discovered the items he hoarded in his backpack. Only after discussing this decision with him was it discovered how much more difcult it is for him to get rid of or “purge” items than resist picking them up to begin with. Finally, it is important to build reinforcement and opportunities to celebrate successes into video game–themed treatment plans. This can be done by creating a level dedicated to celebrating successes or by identifying agreedupon reinforcements for each level won. Ned chose to create a level where he and his dad would go fshing as a way to celebrate his success. He decided that he did not need video game metaphors to help him remember this level.

Ned’s Video Game–Themed Treatment Plan Table 3.2 Ned’s video game–themed treatment plan Level One Savanna biome (school) 1. Steve (Ned) 2. Entity 303 (teacher) 3. Friend (Kamoni) 4. Creeper (anxiety)

Level Two

Planes biome (bedroom) 1. Steve (Ned) 2. Herobrine (boredom) 3. Friends (parents) 4. Creeper (sister) 5. Cow (dog Oscar) 1. TNT (mind) Tools needed 1. TNT (mind) 2. Minecart (ignoring) 2. Flint/steel (breathing) 3. Lava (gum) 3. Clock (books) 4. Clock (books) 4. Fishing rod 5. Flint/steel (purging) (breathing) 5. Enderpearl (meditate) How to earn 1 point = practicing 1 point = dealing with boredom on skills points 2 points = not picking own 2 points = Enderpearl something up (meditate) at night 3 points = leaving a 3 points = purging paper clip behind from backpack 30 points/day for 3 25 points earned Level won when consecutive weeks Environment/ setting Main characters Video game name (Real name)

Level Three Fishing in a real lake 1. Steve (Ned) 2. Friend (Dad) 3. Friend (Kamoni) 4. Entity 303 (fish) 1. Real fishing rod 2. Bait 3. Cloudy weather 4. Good luck 1 point = sunfsh 2 points = bass 3 points = pike

Have fun!

Metaphors Be With You

35

Common Questions and Answers Question How do I know how to interpret a character diagnostically?

Answer As with other experiential approaches to therapy that involve looking for themes and metaphors in play, using client characters diagnostically is a subjective process that requires the mental health provider to explore choices and patterns collaboratively with the client, allowing her/him to shed light on meaning. Learning to notice things such as the absence of ears on a character representing OCD comes with practice and experience but is not required to involve problem-based characters in the process of making a diagnosis. Often, there are multiple “mini-bosses” that work for or combine to make a big boss, so being careful to collaboratively examine the relationship between these diferent characters is essential to understanding the client’s experience with and relationship to the problem.

Question What if I am not familiar with the video game my client is referencing?

Answer Ask the client to tell you about it! Consulting Part 2 of this book to see if the video game in question is included may also provide ideas for other questions to ask or activities to consider.

Question What are some good character creators that can be used for externalizing problems (“characterization”)?

Answer Tablet- and phone-based character creators seem to come and go rather quickly as new apps are created and old apps stop being updated by the developers. Luckily, there are always dozens available to choose from that include a variety of themes and options for customization. Some of my favorites are Freakatars and Blob Monsters. Many popular console and PC games also have excellent character creators.

36

Metaphors Be With You

Question How are points tracked between sessions?

Answer It is seldom easy to successfully engage clients in self-monitoring. The video game–themed treatment planning process described in this chapter will only go so far without efort to track progress toward level completion. There are several possible ways to track points, and the extent to which clients will need assistance with this from parents and others in their communities of support can vary greatly. Tracking forms and regular check-ins with parents and/or teachers to self-monitor can often be helpful. Apps can also be a helpful tool for tracking client progress/points. “Epic Win” is one app I have used efectively for this purpose in the past. More recently, I  have used “Repetition Rebellion,” an app I helped develop specifcally for this purpose. Repetition Rebellion continues to be tested and refned as this book is being written in hopes that it can be made available to mental health providers and their clients in the near future. It is described in more detail in Chapter 9.

Question How come it is important to name characterized problems?

Answer Naming the problem (e.g., diagnosis) can help client’s parents and teachers unite with them against the problem (as opposed to communicating in a way that suggests that the client is the problem or that the problem exists within the client) (Madsen, 2007).

Therapist Missions • •

•

Find and play with character creators on your smartphone or tablet. Determine which options ft your clientele the best based on customization options and themes. Create a character that represents a problem in your own life. How come you created it the way you did? What can you learn from creating your own character that will help you discuss client characters with them? Start asking clients about their (least) favorite video game characters.

Metaphors Be With You

37

References Gray, C. (2001). My social stories book. Jessica Kingsley Publishers Ltd. Guzick, A., Cooke, D., McNamara, J., Reid, A., Graziano, P., Lewin, A., Murphy, T., Goodman, W., Storch, E.,  & Gefken, G. (2019). Parents’ perceptions of internalizing and externalizing features in childhood OCD.  Child Psychiatry and Human Development, 50(4), 692–701. Hart, W., Tortoriello, G., & Richardson, K. (2018). Are personality disorder traits ego-syntonic or ego-dystonic? Revisiting the issue by considering functionality. Journal of Research in Personality, 76, 124–128. Jacobs, S., Rice, R.,  & Sugarman, L. (2012, October  18–20). Creating mindGamersTM: Building communication, design and development process with clinicians, game faculty and students. In Brian Winn (Ed.), Proceedings of the meaningful play. n.p., Web.* Madsen, W. (2007). Collaborative therapy with multi-stressed families. Guilford Press. Rice, R. (2016, January 30). Physiological responses to animated triggers for young people with autism spectrum disorder. American Association of Behavioral and Social Sciences Annual Conference. Rice, R., Douthit, K., & Williams, T. (2014). The repetitive behavior spectrum: From helpful to harmful. Autonomy, the Critical Journal of Interdisciplinary Autism Studies, 1(2). Smith, E., Constantin, A., Johnson, H., & Brosnan, M. (2021). Digitally-mediated social stories support children on the autism spectrum adapting to a change in a ‘real-world’ context. Journal of Autism and Developmental Disorders, 51(2), 514–526. Zatloukal, L., Žákovský, D.,  & Bezdíčková, E. (2019). Utilizing metaphors in solution-focused therapy. Contemporary Family Therapy: An International Journal, 41(1), 24–36.

Chapter 4

Using Video Games for Self-Regulation Training

There is an abundance of research, especially recently, that substantiates the value of teaching and practicing psychophysiological self-regulation (PSR) (e.g., mindfulness, yoga, meditation) for a wide array of diagnoses and levels of impairment (e.g., Kuo et al., 2021; Mak et al., 2021; Carvalho et al., 2021). Even the use of video games for emotion regulation has been studied, and it was determined that video games ofer several opportunities for emotion regulation and a challenge for educational and psychological interventions (Carissoli & Villani, 2019). Most of the clients who contributed to the development of the current approach experienced issues with self-regulation in some form, as evidenced by problematic anxiety, behavioral problems, and panic (fght-fight-freeze). In this chapter, ideas for integrating video games into psychotherapy to help clients learn and practice PSR will be outlined. Some of the ideas require that the mental health provider be equipped with a biofeedback sensor. While this may sound intimidating, it does not need to be overly expensive or require much additional training. It also provides another enticing screen-based “hook” for many young clients.

Biofeedback Basics In a nutshell, biofeedback is a mirror for stress. The advent of new technology has helped to elucidate how personal the process of relaxing or “calibrating” (more on calibration later in this chapter) one’s autonomic nervous system is. We now understand that while techniques such as progressive relaxation and “going to your happy place” are helpful for some, others use skills such as feeling and focusing to keep their adrenaline levels, heart rate, and other biomarkers for stress down (i.e., everyone has their own way to relax). This book will not comprehensively cover biofeedback, and those planning to use biofeedback as a regular part of their practice are encouraged to seek out additional training. For many reading this book, a simple and inexpensive biofeedback sensor will be enough to implement DOI: 10.4324/9781003222132-4

Video Games for Self-Regulation Training

39

the ideas in this chapter. The three options with enough evidence basis to consider are heart rate variability (HRV), skin conductance (GSR), and peripheral skin temperature. For the purpose of pairing biofeedback with video games, HRV tends to be the most useful because it can be read using an earlobe sensor, leaving all of a person’s fngers available to press buttons and do the other things necessary to successfully play a video game. HRV is a measure of the variation in time between each heartbeat. This is controlled by the autonomic nervous system and regulates heart rate, blood pressure, and breathing. There are several creative ways to explain how this works to a child in therapy. For example, one way to understand HRV is as a measure of how well one’s heart, lungs, and mind are working together. A possible way to explain this might be: When we are at our best our heart, lungs, and mind are all working well together, as if they are having a great conversation. As stress and anxiety creep into our lives they try to interrupt the heart, lungs, and mind from their conversation, making it harder for them to communicate. The HRV sensor I use is made by a company called HeartMath Laboratories (www.heartmath.com). It is called Inner Balance, and it is a simple-to-use ear sensor that comes in both wired (for Apple devices) or Bluetooth (for Apple or Android devices) and costs approximately $125. The free app the sensor works with includes a screen with a breathing pacer, a screen with a tranquil image, and a screen with line graphs depicting HRV over time. As with many biofeedback sensors, it uses a color system to provide easy-to-digest feedback on a person’s stress level: red for high stress, blue for moderate stress, and green for low stress. It also has a foating threshold that allows for the difculty level to be customized as a user improves at getting to and staying at green. Considering the color system used by the Inner Balance sensor (and many other biofeedback sensors), the short script ofered previously to explain HRV might be expanded to explain the biofeedback sensor as follows: When you are at your best and your heart, lungs, and mind are having a great conversation, the sensor will show green. When your heart, lungs, and mind are a little distracted but still talking the sensor will show blue. This is the color we would probably be at most of the time if we tried to wear the sensor all day. When your heart, lungs, and mind are all of doing their own thing the sensor will show red. This is what happens when anxiety or panic is so strong that it takes over the conversation.

40

Video Games for Self-Regulation Training

Another even more simplifed way of explaining this might be: When the sensor is at red, it’s like anxiety/stress is right here in the room with us. When the sensor is at blue, it’s like anxiety/stress is in the next room over. When the sensor is at green it’s as if anxiety/ stress is outside the building and can’t interrupt your heart, lungs, and mind unless we invite it back in.

The Case of Sam Sam is the Minecraft fan from Chapter  3 who renamed his rage the Termites and his anxiety the Mooing Men. He met criteria for disruptive mood dysregulation disorder (DMDD) that was characterized by frequent outbursts that included screaming, threatening, and property destruction. Sam had several intense behavioral outbursts in therapy that required extended appointments and numerous eforts to de-escalate. He was ten years old when he was referred for mental health therapy by his school counselor, who spent considerable time with him each day in school and saw his potential. The treatment plan depicted for Sam took approximately three months from referral to collaboratively craft because he needed to learn new coping skills using the approaches described later in this chapter (e.g., calibration, pairing video games with biofeedback). Both of Sam’s parents were heavily involved in this process and did an exceptional job of following through on how to support him between appointments, starting with their consistent and efective use of the names the Termites and the Mooing Men. Despite Sam’s love of playing Minecraft, he chose to use Mario Bros./Mario Kart as inspiration. Ribbon Road, Bowser’s Castle, and Rainbow Road are all racetracks in Mario Kart. Based on the urgency involved with improving his behavior at school, Sam chose to start his game there, despite the level of difculty involved (level one is generally where clients confront the easiest constraints to achieving their goals). Sam’s Video Game–Themed Treatment Plan Sam was not the type of kid in therapy who was comfortable or felt helped by talking for an entire hour, even when leveraging video game metaphors. He was a highly intelligent ten-year-old who recognized that he needed to get better at managing his reactions to anxiety but felt unable to do so at that time. In fact, his typical response to being told to calm down by teachers was a very loud “I don’t know how!” He had seen other therapists and was disillusioned with the standard approaches to teaching young people PSR skills (e.g., fgure eight breathing, progressive

Video Games for Self-Regulation Training

41

Table 4.1 Sam’s video game–themed treatment plan

Environment/ setting Main characters # video game name (real name)

Level One

Level Two

Ribbon Road (fourth grade) 1. Mario (Sam) 2. Bowser (1:1 aid) 3. Friend (Larry) 4. The Termites 5. The Mooing Men

Bowser’s Castle (home) 1. Mario (Sam) 2. Bowser (Dad) 3. Luigi (Mom) 4. Princess Peach (dog) 5. The Termites 6. The Mooing Men

Level Three

Rainbow Road (fifth grade) 1. Mario (Sam) 2. Bowser (principal) 3. Friend (Larry) 4. The Termites 5. The Mooing Men 1. Shells (breathing) 1. Mushrooms Tools needed 1. Mushrooms (walking) 2. Banana Peels (self(walking) 2. Shells questioning) 2. Shells (breathing) 3. Video games (breathing) 3. Oil (school 4. Princess Peach 3. Oil (school counselor) (dog) counselor) 4. Banana 4. Banana Peels Peels (self(self-questioning) questioning) 1 point = daily 1 point = daily How to earn 1 point = daily calibration calibration points calibration 2 points = stay 2 points = stay in 2 points = lose in class all day gracefully the classroom 3 points = expressing 3 points = stay for a full class in class all self appropriately 3 points = No week when the Termites more than five or Mooing Men are minutes spent around outside of class each day Level won when 50 points/week for 50 points earned Reputation is 2 consecutive repaired weeks

relaxation, counting to ten). Using video games (and a board game) to teach him these skills proved to be efective where other approaches had fallen short. Most notably, Sam spent nearly 30 minutes of each session learning and practicing PSR skills while gaming by pairing his play with biofeedback. He then used what he learned on biofeedback to develop a calibration routine. As shown on Sam’s video game–themed treatment plan, daily calibration became an important part of his work and earned him one point for every day that he did it. The following sections will describe how to create calibration routines and pair video games with biofeedback. It is important to note that calibration is an important skill that can be learned and practiced regardless of someone’s access to electronic biofeedback.

42

Video Games for Self-Regulation Training

Pairing Video Games With Biofeedback One of the most frequent things many clients say when asked if they use their coping skills to deal with real-life stressors is “I couldn’t. I had to do (the task) that I was being told to do.” People do not usually have the luxury of going to the corner of the room and meditating every time they are stressed. Students cannot put their head down on their desk every time they are frustrated. We need to be able to use the skills we learn to self-regulate within the context of regular life. Pairing video games with biofeedback is one helpful way to help people learn how to do this by requiring that they practice their self-regulation skills while engaged in a stimulating and challenging activity. It is also an exceptionally engaging way to teach self-regulation skills, as it provides many clients with exactly what they want: to be playing video games. Pairing video games with biofeedback can be used early in the treatment process and remains helpful later in therapy, often for diferent reasons. As soon as someone is introduced to biofeedback in a way such as the approach outlined earlier in this chapter, it is reasonable to consider pairing video games with biofeedback. Using the approach outlined next, the difculty level can be increased as people learn new skills. This helps ensure that the process does not get old and motivates people to get better at self-regulating so they can spend more time playing. Later in treatment, pairing video games with biofeedback can be a way to help people achieve the conditions necessary to have difcult conversations in therapy. Focusing on self-regulation, doing something engaging, and speaking with a trusted person while in a side-by-side position are all examples of these conditions. Choosing a Game Choosing which video game to play when pairing with biofeedback can provide tremendous insight into a person’s experience and relationship with stress. The obvious choices are often the action games where players are engaged in high intensity battle or adventure. On the other hand, some people fnd strategy games or games that challenge their intellect to be a better ft when asked to choose a game that is likely to activate their autonomic nervous system. Discussing these choices with people can be an excellent way to evoke valuable data. This data can be used to assist with diagnosis and treatment planning. When possible, co-op games can be an excellent choice when deciding what to pair with biofeedback. Co-op video games are games that involve two or more players working together to achieve a common goal. In individual psychotherapy, this allows the mental health professional and client to emulate collaboration. For the purpose of pairing biofeedback

Video Games for Self-Regulation Training

43

with video games, co-op games provide additional opportunities to manage those times when clients are unable to play because their stress level prohibits them from doing so because the mental health provider also has a controller and can pause the game. Establishing the Rules The rules will depend partially on the type of biofeedback sensor being used and should be collaboratively developed when possible. Typically, and in the case of the HRV sensor used with Sam, a person’s stress is indicated using a color system. Keeping in line with the Zones of Regulation (zonesofregulation.com), red often denotes high stress, blue moderate stress, and green low stress. Using these color codes, a common ground rule when pairing video games with biofeedback is often to request a “pause” from game play when a client is in the red zone. The rules can also sometimes depend on the game being played. For example, sports games are difcult to pause, but ofer opportunities to create scoring advantages or disadvantages related to a person’s relative stress level. One client, “Alec,” was a skilled e-sports player who would routinely destroy me when we played video game basketball during sessions. As a form of “handicap,” we decided to reduce Alec’s score by fve any time the HRV sensor showed red while we were playing. Additionally, Alec was able to choose better teams and players at the beginning of games depending on the amount of time spent in the green zone during a “pre-game calibration.” Other examples of rules that can be established to keep the process of pairing video games with biofeedback fun and productive are only limited by a person’s imagination. Some ideas are as follows: • • • •

Require a client to get all the way back to green before restarting game play. Have clients agree to answer questions about (family, school, mental health) when paused from the video game. Restrict the use of particular tools or weapons in the video game when the client is at blue. Reverse the rules—require clients to pause the game when at green in some circumstances (see My Self-Control Game later in this chapter).

Enforcing the Rules The most simple and reliable way to pause game play when a client is at red is to play side by side with him/her so you can press the pause

44

Video Games for Self-Regulation Training

button on the game controller when necessary. That said, many people will reliably pause the game on their own and put the game controller on their lap when it is time, as long as the expectations for the session are clear. When given the choice, most people will choose to follow the rules when the alternative does not involve playing video games in therapy. Often, learning to self-enforce the rules is an important part of learning how to self-regulate and can become a focal point in psychotherapy when clients struggle to pause game play when agitated/ stressed. Increasing the Difficulty Many biofeedback sensors, including the HeartMath Inner Balance HRV sensor used in several examples in this book, have built-in mechanisms (foating thresholds) for increasing difculty (i.e., how hard it is to get to green). Difculty level is usually changed in app settings and includes options that range from a little too easy to a little too difcult. For a four-level foating threshold, levels two and three are generally the most useful when pairing biofeedback with video games. Other ways to make the process of pairing biofeedback with video games more challenging over time include additional rule changes and deliberate eforts to distract clients during game play. For example, a rule could be added that permits a client to play only when at green or after maintaining low stress for a particular period of time. To distract clients, little siblings can be brought in or portions of the screen can be covered. As with most of the ideas presented in this book, how much and how quickly to increase the difculty involved with pairing video games with biofeedback should be a collaborative process that challenges clients without discouraging or frustrating them. Remember that the goal is to practice skills learned in psychotherapy in a fun and motivating way that values the client’s love of gaming. In general, it is better to err on the side of going too slow than pushing clients further or faster than they are ready for. Providing a structured transition from playing video games in therapy to ending the session and returning clients to their parents is also highly advised, especially for clients who tend to struggle with “getting of the screen.” In this way, pairing video games with biofeedback can also contribute to improved self-regulation when ending a gaming session.

Teaching Calibration With Video Games A common client and parent complaint is that “He understands how to use his breathing when he is in the ofce for therapy but has a hard time

Video Games for Self-Regulation Training

45

applying the skill when upset.” This is a teachable moment that calls for one or both of the following therapist responses: 1. 2.

“If he calmed down because you told him to calm down, then that would be the frst time in human history that that has happened.” (If you want to take the sarcastic route) “The best time to use these skills is when things are going well.” (Followed by psychoeducation on calibrating the autonomic nervous system—see next)

One of the most powerful things a client can learn about PSR is the concept of calibration. In the same way that car engines and musical instruments need to be calibrated, our autonomic nervous systems are highly subject to going out of tune and establishing a new baseline if we spend enough time in a particular state of arousal. By practicing the abdominal breathing and other skills learned in psychotherapy as a daily routine when things are going well, a person can limit the frequency and intensity of excessive autonomic arousal (e.g., Kuo et al., 2021; Sugarman & Wester, 2007). That’s not to say that it is not helpful to use one’s skills when in fght-fight-freeze, only that those skills will be far more natural, accessible, and efective if used as part of a calibration routine. In this way, calibration helps people prevent extreme episodes of dysregulation and develop a sense of confdence that they can use those same skills (without needing someone to tell them to “calm down”) when they are needed most. Video games and related metaphors can often be helpful when working with clients to consider and implement calibration routines. For example, video game imagery and metaphors can be used with clients to remember the role and timing of calibration. Take, for instance, the case of Dean, a transition-age youth diagnosed with both ASD and OCD. The Case of Dean Consistent with DSM-5 criteria for ASD, Dean presented with several restricted, repetitive behaviors that often impacted his functioning and limited his productivity at school and work. For example, he would straighten shoes, look for squeaks in the foor, and take excessively long showers. When asked, Dean reported that these behaviors helped him relax. A more thorough assessment suggested that these behaviors did not follow an obsessive-compulsive process and, therefore, should not be treated with the same CBT strategies that might be used for repetitive behaviors in OCD (see Chapter 5 for more on this). Dean was an avid Nintendo gamer who most loved playing any game that included Mario, especially the many iterations of Super Mario. In

46

Video Games for Self-Regulation Training

Super Mario games, mushrooms generally serve the purpose of “poweringup” Mario, a term that is common in gamer culture and applies to many video games. It generally involves adding strength, health, and/ or abilities to an avatar. After some consideration, Dean decided that his repetitive behaviors served a similar purpose for him as mushrooms do for Mario—straightening shoes were green mushrooms; checking for squeaks in the foor were red mushrooms; and excessively long showers were blue mushrooms. Each played their own unique role in helping Dean “power-up.” We decided that this was how Dean calibrated and agreed that it would be helpful if he could fnd other ways to calibrate as well that took less time and drew less attention to him. Over time, Dean learned abdominal breathing and mindfulness skills and decided that he was ready to start using them as part of a calibration routine. He started by practicing them in addition to his repetitive behaviors and discussed in therapy how each skill compared to the green, red, and blue mushrooms that he had been using for so long to calibrate before he had learned them. He agreed to start using his mindfulness skills as a replacement for checking for squeaks in the foor because in his mind it served a similar purpose. Mindfulness now became the red mushroom. Later in therapy, he replaced straightening the shoes with abdominal breathing, allowing it to become the green mushroom. The blue mushroom stayed the shower, but we were able to leverage video games to cut their length dramatically (more on this in Chapter 6). Utilizing the Mario mushroom metaphors to remember these skills also provided a framework for helping Dean remember when to use them as part of a calibration routine. As an expert in Super Mario games, Dean knew exactly where to fnd any and all types of mushrooms regardless of the version of the game or level. He was able to use this knowledge in therapy to respond to the question, “If your house was a level in Super Mario Bros., which level would it be and where would you fnd the mushrooms?” Dean had no problem visualizing this and, not surprisingly, he placed the red mushroom where the squeaky foors were and the green mushroom near the shoe rack. I then asked him, “Now when do you think you would need these power-ups?” Dean was decisive in his answer, “I will need the red mushroom before school to power-up for the day and the green mushroom after school to power-up for homework.” Of course! No wonder Dean had developed repetitive behaviors in the dining room (where he ate breakfast and got ready for the day) and the shoe rack (where he entered the house after school)! Those locations had always been important, it just wasn’t apparent why until we discussed his house as a level in Super Mario Bros. With the image of himself as Mario, Dean began working on using his abdominal breathing to calibrate before school and his mindfulness skills to calibrate after school. He was able to remember when to do this because he knew exactly where to fnd the mushrooms.

Video Games for Self-Regulation Training

47

My Self-Control Game Before video games, board games were in many therapists’ toolbox as a way to build rapport and create a comfortable environment. Many games have also been created specifcally for use in psychotherapy (e.g., Thinking-Feeling-Doing Game, Coping Skills Bingo). My Self-Control Game was developed as a way to make the process of learning selfregulation skills more fun and dynamic. It combines HRV with a customizable board game to help practice controlling stress responses. A fullsize version and play instructions are included in the appendix of this book. Mental health providers using this book are encouraged to get creative with My Self-Control Game by collaboratively creating new rules with clients and to allow for use with diferent forms of biofeedback. Sam and others who have used My Self-Control Game as part of their therapy appreciated how it helped them practice their selfregulation skills in ways that ft their lives. The HeartMath Inner Balance sensor that Sam wore when he played it depicts HRV with colors: red for low, blue for medium, and green for high. The higher (“greener”), the calmer. While playing My Self-Control Game, clients are instructed to change their HRV by increasing and lowering it to match the color of the game board section under their playing piece (this could be a

Figure 4.1 Biofeedback board game

48

Video Games for Self-Regulation Training

rock, video game fgures, or just about anything else the mental health provider has available). They are then instructed to hold that zone for two “pings” before advancing to the next segment. Ultimately, the player is supported in doing this until he/she reaches the end and earns a small reinforcement (e.g., satisfaction of winning, video game fgure, trading card). My Self-Control Game can be made more challenging or complicated by adding additional rules (described in more detail in the full instructions to My Self-Control Game in the appendix of this book). It takes tremendous self-control to change color score in either direction, making this approach exceptionally valuable when learning selfregulation skills. It is one thing to learn to relax and what that feels like, it is a whole other and highly powerful thing to understand what it feels like all along the stress spectrum, and how to implement self-regulation skills at diferent points on it. When people are able to raise or lower their biomarkers for stress at will, they understand how their autonomic nervous system works at a higher level that provides enhanced awareness during panic and appreciation when relaxed. Other possible ways to help gamer clients achieve this level of awareness are: 1) reverse the expectations/rules when pairing video games with biofeedback and 2) instruct clients to change their biomarkers for stress based on where they are in a particular video game. For example, clients playing a game that involves boss battles could be instructed to increase their HRV prior to battle.

Conclusion Video games provide an ideal context for learning and practicing selfregulation skills because they can evoke a wide array of emotions and require a variety of cognitive tasks. The mere act of choosing a game to play can provide valuable insight into a client’s relationship with stress. By leveraging the benefts of video games when teaching PSR, mental health providers can engage clients in experiences that allow them to explore self-regulation along a spectrum and practice new skills in a safe and fun manner. Techniques such as biofeedback and calibration can enhance this process, especially for clients who experience high levels of autonomic arousal throughout much of their day.

Common Questions and Answers Question What if my client is having a hard time remembering to calibrate and Dean’s approach is not a good option?

Video Games for Self-Regulation Training

49

Answer Helping clients remember to do what they agree to do in therapy between therapy sessions is a common barrier to progress. Many mental health providers choose to view this type of behavior as resistance, resulting in frustration, over-responsibility, and inefective responses. Generally speaking, it is much more useful in psychotherapy to view a client’s poor compliance with therapy homework as an opportunity to understand what constrains that client from doing better (Madsen, 2007). Adding new things to one’s routine can be a challenge, even when those things are simple to do. One way to help clients remember to calibrate while learning what constrains them from remembering more naturally is to pair calibration with something that is already embedded in their routine. For example, by placing a sticky note on the bathroom sink a client can remind her/himself to calibrate in the shower or after brushing her/his teeth. Or calibrate every time before playing a favorite video game.

Question What is the minimum equipment I  need to pair biofeedback with gaming?

Answer While it is helpful to have an actual biofeedback sensor (e.g., HRV, skin conductance, skin temperature) to implement many of the approaches outlined in this chapter, many of the same skills can be taught and practiced using lower-tech options if that is all that is available. Biofeedback is simply a mirror for stress, and as such, something as simple as an actual mirror can sometimes be enough to help someone get the feedback she/he needs to make a change. Heart rate, abdominal expansion, and breath rate are not always a good indication of what is actually happening in someone’s autonomic nervous system, but they can be useful alternatives to HRV in a pinch because they still provide clients with something tangible to change. A gaming computer or video game platform, while helpful, is also not a necessity to do this work. As phones and tablets become more advanced and accessible, they provide more gaming options that are equally appealing as gaming platforms. Many of the most popular video games now have popular mobile versions (e.g., Minecraft, Super Mario, Pokémon games).

50

Video Games for Self-Regulation Training

Question How is Sam doing now?

Answer Sam successfully navigated middle school and maintained his academic placement. He is now an honor student in high school. He remains an avid gamer and continues to enjoy Minecraft and Super Mario games the most. The Termites and Mooing Men remain part of his life, but he is far more capable of dealing with them when they show up because of the work he did in therapy. He is excited to be an expert consultant on this book.

Question I thought I didn’t need to be a gamer to use this book! How do I do this work if I stink at playing video games?

Answer Sometimes it is better when the mental health provider stinks at playing video games! Especially for younger clients, there can be great value in their experience of themselves as an “expert” when they are beating up on their mental health provider in a video game. It can be an excellent way to change the dynamic in therapy so that clients feel less judged and more competent. For this same reason it can be helpful for mental health providers to ask clients for help playing games better and be curious about games and how clients became so profcient at them.

Therapist Missions • •

Consider purchasing a biofeedback sensor and practice using it on yourself. Develop and implement a personal calibration routine and consider how you might describe calibration to clients.

References Carissoli, C.,  & Villani, D. (2019). Can video games  be used to promote emotional intelligence in teenagers? Results from emotivaMente, a school program. Games for Health, 8(6), 407–413. Carvalho, S., Xavier, A., Gillanders, D., Pinto-Gouveia, J., & Castilho, P. (2021). Rumination and valued living in women with chronic pain: How they relate to the link between mindfulness and depressive symptoms. Current Psychology: A Journal for Diverse Perspectives on Diverse Psychological Issues, 40(3), 1411–1419.

Video Games for Self-Regulation Training

51

Kuo, J., Zeifman, R., Morrison, A., Heimberg, R., Goldin, P., & Gross, J. (2021). The moderating efects of anger suppression and anger expression on cognitive behavioral group therapy and mindfulness-based stress reduction among individuals with social anxiety disorder.  Journal of Afective Disorders, 285, 127–135. Madsen, W. (2007). Collaborative therapy with multi-stressed families. Guilford Press. Mak, W., Chio, F., Chong, K., & Law, R. (2021). From mindfulness to personal recovery: The mediating roles of self-warmth, psychological fexibility, and valued living. Mindfulness, 12(4), 994–1001. Sugarman, L.,  & Wester, W. (2007). Hypnosis with children and adolescents: A contextual framework. In W. C. Wester II & L. I. Sugarman (Eds.), Therapeutic hypnosis with children and adolescents (pp. 3–24). Crown House Publishing Limited.

Chapter 5

Using Video Games for Anxiety Disorders

Most people who contributed to the ideas in this book experience some level of anxiety; many meet criteria for an anxiety disorder, such as obsessive-compulsive disorder (OCD). One explanation for this is the high prevalence of anxiety and OCD in autism spectrum disorder (ASD) (Hessl et  al., 2021; Schiltz et  al., 2021), another area of focus in this book (more on ASD in Chapter 6). Thankfully, video games have also been a useful tool for helping young clients with anxiety disorders, as these games lend themselves well to incorporating many of the cognitive behavior therapy (CBT) concepts generally used for this purpose, such as externalization and exposure and response prevention (ERP). The ideas presented in this chapter represent only a small sample of how and in what capacity video games are already being used to treat anxiety. There is a growing body of research examining the efects of casual video games on anxiety and depression. Pine et al. (2020) did a meta-analysis based on a systematic search using terms such as “casual game,” “casual video game,” “minigame,” etc. and mental health, anxiety, depression, stress, or mood. Thirteen studies met inclusion criteria for the analysis, reporting fndings for nine diferent casual video games, with six studies aimed at reducing anxiety, two examining the efects for depression, and four investigating the efects of casual video games on treating stress or low mood. Promising efects were identifed across the board, leading the researchers to conclude that even casual video games may have promise for treating anxiety, depression, stress, and low mood.

The Case of Alan Upon referral, “Alan” was a nine-year-old boy with a variety of fears and anxieties. He did not know his parents were planning a divorce, which they feared would exacerbate his anxiety—it did. He was seen one hour every two weeks for approximately six months, then closer to monthly after that. His parents, who described him as a “timid” kid, both participated in his appointments. DOI: 10.4324/9781003222132-5

Using Video Games for Anxiety Disorders

53

The frst several appointments with Alan were a challenge. He spoke very little and retreated to the corner of the room every time he was engaged. As is often the case when a child demonstrates this type of avoidance at frst, his parents reported that he was a “chatter box” at home and had a “great sense of humor.” They also said that he enjoyed video games in his down time. Challenge accepted. It was around the fourth appointment when Alan frst brought his stufed Pokémon, Pikachu, to a therapy appointment. From that point on everything would change. Alan participated regularly in therapy and even asked his parents to schedule appointments. Pikachu became a “mental health therapist in training,” with the assistance of a stufed brain cell named Simon that was kept in the therapy room as a prop to help describe how psychotropic medications work (more on this later in this chapter). Pikachu knew everything about Alan and his anxiety and was happy to answer Simon’s questions, especially when Simon used Pokémon metaphors to communicate his points. Pikachu told Simon that Alan was afraid of strawberries, fre drills, and zombies, with strawberries posing the biggest risk to his safety based on what OCD told him would happen if he came in contact with its juice or someone who had. Fire drills scared Alan because he did not like the noise and they reminded him that “school is not totally safe if it can burn down.” Zombies scared Alan because his older cousin told him that if he looked in the mirror for too long a zombie could come through it. This was believable to Alan, who had seen this happen on a zombie video game that he often played with said cousin. Using this information, we were able to start creating Alan’s video game– themed treatment plan, starting with what Alan would be focusing on at each level. Alan did not hesitate when rank ordering his fears: strawberries were the scariest (big boss), zombies were the second scariest (head mini-boss), and fre drills were the least scary (“but still really scary”). Thus, level one would address fre drills, level two would address zombies, and level three would address strawberries. Alan did not like the idea of confronting his fears but seemed relieved (as do many people) to know that the strongest of his fears would be saved for last and he would have time to work up to confronting them, just like building skills and acquiring new tools in a video game. Alan also decided that each level would take place in a diferent region of the Pokémon games, important details that Pikachu was more than happy to share with Simon, shedding additional light on the nature of each fear. Level one involved using his skills to better handle fre drills. When asked where school would be in Pokémon, Alan said that it would be a Pokémon gym, which existed in most towns in Pokémon games. Level two involved confronting his fear of zombies jumping out of bathroom mirrors. He decided that level two would be represented by the hometown that players of Pokémon experience at the beginning of each game because most of the work was to be done in the bathroom at his

54

Using Video Games for Anxiety Disorders

house. Finally, Alan chose to confront his fear of strawberries for level three. He did not hesitate to choose the routes between Pokémon towns to be the environment for level three because that is considered to be an unsafe environment in Pokémon, where battles occur. Next, Alan identifed the main characters in his game, starting with himself, who was represented by his avatar. Other characters were represented by diferent Pokémon who reminded Alan of the actual person. For example, the Pokémon Alakazam was his teacher because it is associated with knowledge and learning and was the “fnal evolution of the most advanced form in an evolutionary line.” Chansey was the school counselor in Alan’s video game–themed treatment plan because “She is a nurturing egg-shaped Pokémon with a pouch whose nature is to take care of others and spread happiness.” Alan chose the Pokémon Kangaskhan to represent both of his parents because “it can fght, but it is always fghting to protect its child.” Finally, Pikachu represented Alan’s friends because it is “an excellent ally, reliable partner, and friend in the TV show.” The level bosses were also represented by Pokémon, as described in the next section. To remind him of the strengths and skills he would need to confront anxiety in each circumstance, Alan chose Pokémon weapons, some of them based on fan fction. For example, armor represented the headphones he used to protect his ears from the noise of fre drills. His abdominal breathing and other psychophysiological self-regulation skills were represented by a bow. To round out Alan’s tools, logic was represented by a sword, assertiveness an ax, courage a shield, and the CBT technique RIDE (more on this later in this chapter) was represented by a staf. Using these tools, Alan would earn points based on a system that he collaboratively developed in therapy, ultimately achieving victory and reaping the rewards of his success—a new Pokémon card set he had his eyes on. Alan’s Video Game–Themed Treatment Plan Table 5.1 Alan’s video game–themed treatment plan

Environment/ setting Main characters Video game name (Real name)

Level One

Level Two

Level Three

Pokémon Gym (school) 1. Alan 2. Exploud (fire drills) 3. Pikachu (friends) 4. Chansey (school counselor) 5. Alakasm (teachers)

Hometown Routes (kitchen (bathrooms) at home) 1. Alan 1. Alan 2. Gengar (zombies) 2. Vileplume 3. Pikachu (friends) (strawberries/ OCD) 3. Kangaskhan (parents) 4. Pikachu (friends)

Using Video Games for Anxiety Disorders

55

Table 5.1 (Continued) Level One Tools needed 1. Armor (headphones) 2. Bow (breathing) 3. Sword (logic)

Level Two

Level Three

1. 2. 3. 4.

Bow (breathing) 1. Bow Ax (assertiveness) (breathing) Shield (courage) 2. Staff (RIDE/ Sword (logic) GAME) 3. Sword (logic) 1 point = calibrating See ERP plan How to earn 1 point = calibrating (later in this daily points daily chapter) 2 points = participating 2 points = Use bathroom at home in fre drill with help and look in mirror of Chansey (school 3 points = Go into counselor) bathroom to look 3 points = participate in mirror even in fre drill without when I don’t need support to go, just to look in the mirror Level won At least 21 points 25 points earned “I can hold a when earned with at least strawberry in two independent my hand” fire drills

Using Avatars to Diagnose and Understand a Person’s Relationship With Anxiety Alan’s story illustrates how avatars can be used to help understand the relationship between clients and anxiety. Each of his fears was presented during assessment as representing the same thing, anxiety, but little efort had been made to understand the actual function* of Alan’s anxiety and response to it in each circumstance. This was an important process in his therapy because it turned out that each of his reported fears played a very diferent role in his life. We learned this partly by assigning Pokémon to represent each of his fears in the video game–themed treatment plan. When discussed in therapy, it became clear that his motivation for choosing these Pokémon was not merely an act of favoritism. Specifcally, Alan chose to have his fear of fre alarms to be represented by the Pokémon Exploud, an especially loud character in the game; his fear of zombies to be represented by the Pokémon Gengar, a ghost made from poisonous gas; and his fear of strawberries to be represented by Vileplume, a toxic corpse fower that is a type of fungus. If you touch it or breath its spores in the game, you die. Alan drove his decision home by saying, “It also smells like decaying fesh.”

56

Using Video Games for Anxiety Disorders

By examining Alan’s Pokémon choices in therapy we were able to understand the functions for these behaviors better. The loud Pokémon Exploud bothered Alan at a sensory level and made him want to escape the situation. Gengar was a mysterious and creepy character that was based on a supernatural premise and made Alan feel scared and out of control when he thought about him (cognitive-based fear). Vileplume was a Pokémon that could cause actual harm to Alan and reminded him of something he knew existed in real life (behavioral-based fear). The way Vileplume worked reminded Alan of how he felt about strawberries as “invading his thoughts.” With an improved understanding for each of the repetitive behaviors he referred to, Alan embarked on three very diferent missions, with only the strawberry fear meeting criteria for OCD and warranting extensive CBT, including ERP (described in the next section). The Claws from Chapter 3 is also a good example of using avatars to understand a person’s relationship with anxiety. As outlined in that chapter, the creator of the Claws was a young man who was diagnosed with both autism and OCD. At referral, it was unclear whether his repetitive behavior followed an obsessive-compulsive process or one more typical of a person with autism (e.g., preoccupation, perseveration). Ultimately, discussing the Claws helped its creator to communicate how his fear of germs ft the intrusive and risk-avoiding properties of OCD better than the internalized and metaphoric properties of many repetitive behaviors exhibited by people with autism (Rice et al., 2014).

Video Game–Themed Exposure and Response Prevention Alan’s ERP plan is a good example of how video games can be used to help young clients understand and be motivated to confront their fears head on. As expected, strawberries proved to be Alan’s biggest nemesis, the big boss, and ERP was required to confront the obsessive-compulsive process involved with his fear of their “terrible juice.” Alan’s ERP plan was set up much like his video game–themed treatment plan, using gamer metaphors to represent diferent levels in his plan. Each level involved varying degrees of strawberry confrontation, with the early levels including battles only with mini-bosses who had simply come in contact with strawberries (e.g., Alan’s sister when she eats her favorite strawberry oatmeal). Alan reluctantly agreed that the game would require holding an actual strawberry to win it, expressing his disgust in no uncertain terms when it was proposed by his father that he should need to eat one. The early stages of Alan’s ERP planning involved asking him about what anxiety told him when he was exposed to strawberries. Alan’s strawberry compulsion was especially difcult to treat because there was something that was constraining him from seeing it as ego-dystonic, or at least admitting

Using Video Games for Anxiety Disorders

57

as much. In some circumstances, Alan was able to recognize that his fear of strawberries was unwarranted and that they were not going to cause him physical harm, but he typically stopped short of fully externalizing his fear of strawberries because he knew that doing so would take away his leverage to avoid fully confronting them. For this reason, we started Alan’s ERP by focusing only on those circumstances where he acknowledged that his fear of strawberries was being caused by OCD. This dichotomy also infuenced the way Alan created the environment for his game and who the main characters were (e.g., OCD does not make an appearance in level two because Alan was not ready to acknowledge that his fear of strawberries was infuenced by OCD in the situations represented by that level). A Sample of Alan’s Video Game–Themed ERP Plan (Nine Levels Total) Table 5.2 Alan’s ERP plan Level One Environment/ Route 1 setting Main characters 1. Alan Video game 2. Vileplume name (strawberries/ (Real name) OCD) 3. Kangaskhan (parents) Tools needed 1. Bow (breathing) 2. Staff (RIDE/ GAME) 3. Sword (logic) How to earn 1 point = imaginal points exposure using virtual reality strawberries

Level won when 10 points in therapy session

Level Two

Level Three

Route 2

Route 3

1. Alan 2. Kangaskhan (parents)

1. Alan 2. Vileplume (strawberries/ OCD) 3. Kangaskhan (parents) 1. Bow (breathing) 2. Staff (RIDE/ GAME) 3. Sword (logic) 3 points (week 1) = hold strawberry in tin foil only 3 points (week 2) = hold strawberry on napkin

1. Bow (breathing) 2. Staff (RIDE/ GAME) 3. Sword (logic) 3 points (week 1) = hold strawberry wrapped in tin foil and sealed in Tupperware 3 points (week 2)  = hold strawberry in Tupperware only 9 points/day for 9 points/day for two weeks two weeks between between therapy therapy sessions sessions AND hold strawberry at next appointment

58

Using Video Games for Anxiety Disorders

Up and Down the Worry Hill—Gamer Style In 2003, Aureen Pinto-Wagner wrote a book for children that provided a wonderful metaphor for helping them understand OCD and how to deal with it using evidenced-based CBT strategies. Since its publication, Up and Down the Worry Hill: A  Children’s Book about Obsessive-Compulsive Disorder and Its Treatment has helped many young people with OCD and their parents create language that would make the process of discussing this mysterious (and sometimes embarrassing to talk about) disorder in a comfortable and simplifed manner. Using the metaphor of riding a bicycle up and down a hill, Pinto-Wagner was able to help children with OCD understand the timeline for how the disorder works and what that means for confronting it. Specifcally, children with OCD were able to comprehend how anxiety tends to be strongest early in the process of a compulsion, when OCD is telling the child that something bad will happen if they do not do what they are told. Pinto-Wagner (2003) likened this stage in obsessive-compulsive anxiety to riding a bicycle up a hill. That same “worry hill” metaphor is used to remind children with OCD that the anxiety tends to diminish after children use their skills to confront OCD; just like how riding a bicycle down a hill is easy and fun once the hard work of riding up it is done. Pinto-Wagner cleverly used the acronym RIDE as a pneumonic for the CBT skills that could be used to deal with OCD in the moment. R stands for Rename the thought and refers to the process of externalization that takes place at the start of every successful confrontation with OCD (i.e., “This is OCD. I don’t really need to do this”). I stands for Insist that you are in charge (i.e., of your behavior in this moment). D stands for Defy the OCD or Do the opposite of what OCD is telling you to do. This is easily the most complicated and often difcult part of the process that PintoWagner outlined and refers to the person’s decision to actively resist the pull of the OCD by doing the opposite of what OCD is telling her/him to do. Many people (including mental health providers) fall short when implementing this strategy, interpreting it as “ignoring OCD” when in fact defying OCD can sometimes look even more nonsensical than engaging in the compulsion that OCD demanded in the frst place. For example, for a person who has OCD that is telling him to avoid contact with a surface, defying OCD might involve excessive contact with that surface. E stands for Enjoy your success and correlates nicely with the feeling that many people enjoy while riding their bicycles down a hill after struggling to get to the top. Pinto-Wagner’s (2003) model has helped thousands of children and their families and infuenced the ideas described in this book, but there is one problem—many children do not ride their bicycles anymore! (See Chapter 11 for solutions and ways to avoid nature defcit disorder.)

Using Video Games for Anxiety Disorders

59

Instead, this time is spent on screens, playing video games. As a result, the metaphor of riding a bicycle up and down a metaphorical worry hill does not resonate with many of today’s children and adolescents. While the RIDE technique still provides an evidenced-based way to help young people deal with OCD, a new metaphor has become necessary. Luckily, many video games provide the same sense of struggle, followed by increased ease, fun, and accomplishment. Implementing this metaphor in psychotherapy is generally easy to do—simply ask the client about a game she/he played that was difcult and frustrating at frst but easy and fun once they stuck with it. Some common examples that come up in therapy are League of Legends, Escape from Tarkov, Minecraft, and Tetris. The acronym RIDE can also be changed when working with gamers. Instead, GAME can serve the same purpose. In fact, some of the subtle changes made by changing the acronym to GAME have been even more helpful than RIDE for many of the clients who infuenced the ideas outlined in this book. Specifcally, GAME can be used to remember the following steps in CBT for OCD: Gather information Assert self Make the thought the victim Enjoy your success (or Epic win!) Gather information replaces Rename the thought to remind people to ask themselves the types of questions necessary to externalize the thought. For example, “Is this something that I really need to be worried about, or is this OCD playing tricks on me?” or “What is the worst thing that will happen if I don’t do what OCD is telling me to do?” or “Is this something that most people would be anxious about?” Ultimately, by asking the right questions a client can naturally externalize the thought, thereby renaming it and making it ego-dystonic. Many of the people who infuenced the ideas in this book found that this reminder to gather information was more helpful when compared with starting at renaming the thought (i.e., “This is OCD”). Assert-self replaces Insist that you are in charge to remind people to make a conscious choice to confront OCD after determining through the information-gathering process that it is appropriate to do so. Assertiveness is often an underappreciated set of skills and essential for efectively dealing with OCD using CBT (Bienvenu et  al., 2004). Alan and many others included assertiveness skills training as part of their treatment plans to position them well for success with CBT. Make the thought the victim replaces Defy the OCD (or Do the opposite) as the next step in the process. This is probably where GAME difers the most from RIDE because it requires the client to make a conscious efort to

60

Using Video Games for Anxiety Disorders

use OCD’s tricks against it. Many people fnd this to be a useful concept because it creates a dilemma for OCD that it cannot possibly work its way out of when implemented properly. To Make the thought the victim, clients are instructed to respond to obsessive thoughts with a reverse thought that uses the same magical power that OCD was trying to use to bully them in the frst place. For example, instead of following through on an obsessive thought to “touch a table three times or something bad will happen,” clients will immediately create a “reverse compulsion” (i.e., “If I DO touch that table three times then something bad will happen”). Another example might be a person who has excessive anxiety related to washing her hands. In this case, “The Wizard of Logic” can also become a useful character, educating the client on the importance of exposing oneself to germs in order to build a healthy immune system. As with doing the opposite, the reverse compulsion is equally nonsensical as the compulsion itself but allows the client to take control back from OCD in the relationship. Making the thought the victim also suggests a deliberate efort to actively confront the OCD, rather than passively, as when people simply choose to ignore the obsession until it subsides. Enjoy your success (or Epic win!) is the fnal step in the process and is the same as in Pinto-Wagner’s (2003) RIDE. This step seems simple enough but should not be overlooked. Confronting OCD is hard work, and for many children it feels like it would be much easier to keep listening to OCD than to listen to a mental health provider that their parents forced them to talk to. Enjoying your success can be as simple as taking a moment to pat yourself on the back or as complex as a sophisticated reinforcement system with video game rewards for reaching milestones in therapy. Every successful confrontation with OCD in therapy should be considered an epic win.

Video Game Imagery to Help Medicine Work Better The use of psychotropic medicines to treat anxiety and OCD for children and adolescents has sky-rocketed in the past 30 years (Chirdkiatgumchai et al., 2013; Bachmann et al., 2016), especially selective serotonin reuptake inhibitors (SSRIs) (Zito et al., 2002). Despite this dramatic rise in the use of medicines such as SSRIs to treat anxiety disorders, many clients, especially children, do not understand what they are taking and how it is supposed to work. Research has demonstrated that people can increase the likelihood that a medicine will help them if they understand how it is supposed to work and are able to engage in regular mindful practices to reinforce this mechanism (Flore et al., 2019). Take for example Re-Mission, a video game that was created to help young people with cancer respond more favorably to their chemotherapy.

Using Video Games for Anxiety Disorders

61

Re-Mission is a video game where the player, usually a young person diagnosed with cancer, enters a fghter pod and travels through a human body searching for cancer cells to zap and destroy. It was developed to emulate the mechanism involved with chemotherapy treatment and can be customized based on a person’s particular type of cancer (e.g., bone, blood, etc.). Kato et al. (2008) found that adherence to chemotherapy treatment was greater for people who played Re-Mission, concluding that the video game intervention signifcantly improved indicators of cancer-related self-efcacy in young adults. Researchers have also speculated that the action of playing Re-Mission can infuence the mind–body connection in such a way that improves its efect. It is not understood whether this can be attributed to the placebo efect or a more direct cause-and-efect relationship involved with playing the video game. As a result of promising research and games such as Re-Mission, many of the clients who informed the ideas in this book are provided with psychoeducation on how their psychotropic medicines work. Then, as a way to help them remember this information and maximize the potential for a mind–body beneft, they are supported with identifying or creating a video game that they can play in their imagination daily (usually when going to sleep) that emulates the biochemical process of their prescribed psychotropic medications. For example, it should be no surprise based on the prevalence of psychotropic medication prescriptions for children and adolescents that many of the young people who infuenced this book are prescribed SSRIs. Most of these same young people (and their parents) reported that they did not know how their medicine worked because it was never explained to them; presumably because the prescriber assumed that the child would not be able to understand the complex mechanisms involved with regulating the amount of serotonin that a synapse comes in contact with. A simplifed approach that leverages most young people’s knowledge of technology is outlined below. Using a picture, fgure, or stufed example of a brain cell can often be helpful when delivering it. There are billions of these cells (point to example) in your brain. Imagine that all of those cells have tiny cell phones and that they all need to be able to text each other to help you be at your best and not get too anxious about things that you don’t need to. The problem is, all of those cells share the same data plan and some of them get greedy and use more data than they need. What your Prozac (or other SSRI) does is tries to fnd the greedy cells and stop them from using too much data so that there is enough for everyone. This method tends to work especially well for young people who need to share data with their siblings as part of a family plan. When asked, most

62

Using Video Games for Anxiety Disorders

young people are able to think of a video game that reminds them of this process. For example, Pac-Man can be a great metaphor for an SSRI, with the greedy brain cells represented by pellets and the ghosts represented by anxious/obsessive thoughts. For those who are able, designing a video game that emulates the way their psychotropic medicine works is a great option that can provide tremendous insight into how the client perceives the relationship between their mind, medicine, and anxiety/ obsessive thoughts.

Common Questions and Answers Question I understand that the research suggests that even casual gaming can have a positive efect on anxiety, depression, stress, and mood, but how much gaming is too much?

Answer Each person is diferent in terms of the amount of screen time he/she can consume and still maintain a level of functioning with academic and other tasks and activities. Generally speaking, two hours seems to be the point where many young people begin to perform less well with grades, athletics, and other non-gaming activities. It is a good practice to establish a baseline for how much a person games early in the process of psychotherapy so that goals to reduce screen time can be implemented when indicated. Often, the act of self-monitoring, even for the purpose of establishing a baseline, can be of great therapeutic value.

Question What about coping techniques for generalized anxiety?

Answer Chapter  4 covers the process of integrating video games with psychophysiological self-regulation skills. These same skills are indicated for generalized anxiety (Woods et  al., 2020). Combined with CBT techniques for generalized anxiety such as self questioning (e.g., “What is the worst thing that will really happen here?”) and/or resisting problematic thinking patterns (e.g., all or nothing thinking), these PSR skills can help many people assert themselves against anxiety more efectively.

Using Video Games for Anxiety Disorders

63

Question I do not prescribe. How will I know if my client’s video game imagery is helping his/her medicine work better?

Answer Tracking progress on medicine does not require a license to prescribe and can be an important part of helping a prescriber make decisions about medicines and dosing. Considering the prevalence of psychotropic medication use for children and adolescents, it is important that all mental health providers (not just prescribers) become active in the process of helping people consider how their medicine fts on their toolbelt for dealing with life’s many challenges. Asking clients to self-monitor for improvement (or lack thereof) on medicine and communicating this information to prescribers can dramatically improve outcomes considering the relative infrequency of visits with psychiatrists and pediatricians. In terms of the actual impact of using video game imagery to improve medication outcomes, even if it only improves adherence, it is worth the efort. Furthermore, engaging in the type of meditative practice involved with playing a video game in one’s imagination is widely recognized to be helpful, regardless of one’s diagnosis. If doing so accomplishes nothing more than to support a client in establishing a PSR routine, it is worth the time and efort in psychotherapy.

Question The term “functions of behavior” was used in this chapter. What is that exactly?

Answer A biopsychosocial approach to mental health treatment for anxiety and many other diagnoses in children calls for the inclusion of a functional analysis to help identify possible unmet needs that are motivating a problem behavior. Most approaches to functional assessment, including positive behavior support (Johnston et al., 2006), categorize the possible array of unmet needs or functions using the acronym MEATS. M stands for Medical and is strategically placed frst in the acronym to remind the clinician to rule out medical frst. E stands for Escape and refers to behaviors that are hypothesized to serve the purpose of helping a person escape a non-preferred task, activity, or situation. A stands for Attention and refers to many children’s unmet need to be noticed (negative

64

Using Video Games for Anxiety Disorders

attention is better than no attention at all). T stands for Tangible and refers to behaviors intended to achieve a tangible outcome (e.g., a new video game update). S stands for Sensory and refers to the unmet sensory needs that many children, especially children on the autism spectrum, may experience. In addition to these categories, Control is also often considered as a way to recognize and proactively address the need that many young people have to impact their environments in some tangible way.

Therapist Missions • • •

Consider investing in a small supply of video game dolls or fgurines to aid in play therapy. Consider purchasing a fgure, doll, or stufed version of a brain cell for use when helping clients understand how their psychotropic medications work. Review Pinto-Wagner’s Cognitive Behavior Therapy for OCD in Children (2003; see references for full citation).

References Bachmann, C., Aagaard, L., Burcu, M., Glaeske, G., Kalverdijk, L., Petersen, I., Schuiling-Veninga, C., Wijlaars, L., Zito, J., & Hofmann, F. (2016). Trends and patterns of antidepressant use in children and adolescents from fve western countries, 2005–2012. European Neuropsychopharmacology, 26(3), 411–419. Bienvenu, O., Samuels, J., Costa, P., Reti, I., Eaton, W.,  & Nestadt, G. (2004). Anxiety and depressive disorders and the fve-factor model of personality: A higher- and lower-order personality trait investigation in a community sample. Depression and Anxiety, 20(2), 92–97. Chirdkiatgumchai, V., Xiao, H., Fredstrom, B., Adams, R., Epstein, J., Shah, S., Brinkman, W., Kahn, R.,  & Froehlich, T. (2013). National trends in psychotropic medication use in young children: 1994–2009.  Pediatrics, 132(4), 615–623. Flore, J., Kokanovic, R., Callard, F., Broom, A., & Duf, C. (2019). Unravelling subjectivity, embodied experience and (taking) psychotropic medication. Social Sciences and Medicine, 230, 66–73. Hessl, D., Libero, L., Schneider, A., Kerns, C., Winder-Patel, B., Heath, B., Lee, J., Coleman, C., Sharma, N., Solomon, M., Nordahl, C., & Amaral, D. (2021). Fear potentiated startle in children with autism spectrum disorder: Association with anxiety symptoms and amygdala Vol. Autism Research, 14(3), 450–463. Johnston, J., Foxx, R., Jacobson, J.,  Green, G.,  & Mulick, J. A.  (2006). Positive behavior support and applied behavior analysis. Behavior Analyst, 29, 51–74. Kato, P., Cole, S.,  Bradlyn, A.,  & Pollock, B. (2008). A  video game improves behavioral outcomes in adolescents and young adults with cancer. Pediatrics, 122(2), e305–e317.

Using Video Games for Anxiety Disorders

65

Pine, R., Fleming, T., McCallum, S., & Sutclife, K. (2020). The efects of casual videogames on anxiety, depression, stress, and low mood: A systemic review. Games for Health, 9(4). Pinto-Wagner, A. (2003). Cognitive-behavior therapy for children and adolescents with obsessive-compulsive disorder. Brief Treatment and Crisis Intervention, 3(3), 291–306. Rice, R., Douthit, K., & Williams, T. (2014). The repetitive behavior spectrum: From helpful to harmful. Autonomy, the Critical Journal of Interdisciplinary Autism Studies, 1(2). Schiltz, H., Magnus, B., McVey, A., Haendel, A., Dolan, B., Stanley, R., Willar, K., Pleiss, S., Carson, A., Carlson, M., Murphy, C., Vogt, E., Yund, B., & Van Hecke, A. (2021). A psychometric analysis of the social anxiety scale for adolescents among youth with autism spectrum disorder: Caregiver—adolescent agreement, factor structure, and validity. Assessment, 28(1), 100–115. Woods, B. K., Sauer-Zavala, S., Farchione, T. J., & Barlow, D. H. (2020). Isolating the efects of mindfulness training across anxiety  disorder diagnoses in the unifed protocol. Behavior Therapy, 51(6), 972–983. Zito, J., Safer, D., Gardner, J., Soeken, K., & Boles, M. (2002). Rising prevalence of antidepressants among US youths. Pediatrics, 109(5), 721–727.

Chapter 6

Autism and Video Games (and Anime)

Many of the people who contributed to the ideas in this book meet criteria for autism spectrum disorder (ASD). In some of these cases, the individuals involved identifed with the diagnosis of ASD. Usually, those who identifed with the diagnosis of ASD felt connected to others with ASD and felt pride for many of the unique and important strengths that many people on the autism spectrum exhibit (e.g., skilled with technology, ability to “think in pictures”). In other cases, the individuals involved did not identify with the label of ASD. If there is one thing that is certain when it comes to working with people with ASD, it is “If I’ve met one person with autism, I’ve met one person with autism.” The variability in how ASD presents is so vast that many people even question whether we are considering it correctly as a category, and the latest edition of the DSM-5 included several changes to autism, including the omission of Asperger syndrome and pervasive developmental disorder – not otherwise specifed (PDD-NOS) and the inclusion of a more formalized spectrum based on levels of functioning (American Psychiatric Association, DSM-5 Task Force, 2013). Regardless of how one identifes with the diagnosis/label of ASD, gaming appears to be something that many people who are neurodiverse can agree on (Pluhar et al., 2019; Lane & Radesky, 2019).

Research on ASD and Gaming There have been growing concerns about the amount of screen time for many people with ASD. MacMullin et  al. (2016) documented patterns and impact of electronics use in individuals with ASD compared to typically developing peers. Participants included 172 parents of typically developing individuals and 139 parents of individuals with ASD, ranging in age from 6 to 21 years. In the study, parents completed surveys of demographics and the frequency, duration, and problematic patterns of electronics use in their sample of children, adolescents, and transitionage youth. Parents of individuals with ASD reported signifcantly more electronics use than those of people without ASD. Males used video DOI: 10.4324/9781003222132-6

Autism and Video Games (and Anime)

67

games far more than females, regardless of an ASD diagnosis. Most notably, signifcantly more parents of young people with ASD reported that electronics use was having a negative impact on their lives. These results are similar to previous research related to electronics use among young people with and without ASD. For example, Mazurek and Wenstrup (2013) found that the most common form of play for children with ASD is electronic medias, such as video games or computers. The researchers further reported that children with ASD spend approximately 62% more time playing video games and engaging in electronic activities then being engaged in non-electronic activities. Also, in a large, representative sample of youth from the United States, those diagnosed with ASD had higher rates of non-social media use (television and video games) and lower rates of social media use (email and chat room participation) than other disability groups (learning disabilities, speech/language impairments, and intellectual disabilities) (Mazurek et al., 2012). In terms of the higher rate of gaming among males, Willoughby (2008) also demonstrated that males tend to have a higher rate of problematic video game use than females. When considered along with the fndings of MacMullin et al. (2016) reported on in the previous paragraph, these fndings suggest that boys with ASD are particularly vulnerable to problematic electronic use. This is an area that deserves additional attention in the research, especially given that ASD is diagnosed in 3.25 times as many males as females (Loomes et al., 2017). Most of the people with ASD who contributed to the ideas in this book had others in their lives who were concerned about their video game use at the time of referral. In many ways it is rather ironic that these parents sought out this approach considering its liberal use of video games and related concepts. Despite their mixed feelings about video gaming, they recognized its powerful presence in their loved one’s lives. Gaming in Therapy for ASD Jimenez-Munoz et al. (2021) did a meta-analysis of research looking at video games for the treatment of ASD. Twenty-four articles were included in the review. The results suggested that video game–based interventions were efective for alleviating symptoms, albeit with small efect sizes. In particular, and of note, high rates of acceptability and adherence to treatment were also found. The researchers concluded that exploring commercial video games for the treatment of ASD is an important line for future research, and others agree (e.g., Lane and Radesky, 2019). Other research has looked at developing friendships and an awareness of emotions for young adults with ASD using video games. Gallup and Serianni (2017) did a qualitative study with fve young adults with ASD who actively played a massively multiplayer online role-playing

68

Autism and Video Games (and Anime)

game (MMORPG) in a virtual environment. One of the most signifcant fndings was related to the emotional awareness and expression of the participants, who seemed to beneft from the reduction in extraneous variables provided by the virtual environment (e.g., sound, large groups of people, travel, and face-to-face interactions with unknown entities). The researchers recommended further studies with the goal of developing a larger database of information targeting more comprehensive understanding of the socialization and skill development for individuals with ASD. More on the benefts of virtual environments for people with ASD can be found in Chapters  8 (YouTube and Let’s Plays in psychotherapy) and 10 (virtual reality in psychotherapy).

Video Game Music Believe it or not, the days of buying compact disks or cassettes of your favorite band are long gone. Most young people consume music in much diferent ways than even a decade ago, and video game music is more accessible than ever because of some of these changes. Combined with the immense popularity of video games and money being spent on their development, this increased accessibility has many gamers listening to the background from the opening scene in their favorite video game instead of today’s pop stars. The feelings that video game music incites in the player can be a useful starting point for discussing and examining the experience of emotions outside of therapy. For example, a tremendous amount can be learned by identifying what video game background music a client would choose for diferent parts of his/her life. Is the music for school fast or slow? How about for home? When playing with friends? Each of these contexts have the potential to be relaxing, stimulating, boring, exciting, satisfying, or any combination of these. The pace, beat, and how each video game song makes a person feel can be a great place to start or deepen a conversation with a client about what her/his experience in each context is like. Most of my experience using video game music in psychotherapy has involved working with young people on the autism spectrum. Dean’s case (described next) is one of the most memorable examples. The Case of Dean Upon referral, “Dean” was a 17-year-old young man diagnosed with ASD and OCD. Dean was an avid player of vintage Nintendo video games and arguably knows more about the Super Mario series of games than Mario himself. As with many people who contributed to the ideas in this book, Dean exhibited repetitive behaviors that occupied a tremendous amount of his time and required an assessment to determine whether

Autism and Video Games (and Anime)

69

they were driven by the risk-avoiding and intrusive mechanisms of OCD or the pleasure-seeking and internalized mechanisms common in behaviors such as preoccupations and perseverations (Rice et  al., 2014). Of particular concern, Dean spent as much as an hour and a half every evening in the shower despite regular and strongly worded requests from his parents to spend less time. Initially, it was presumed that Dean’s excessive time in the shower was related to an obsessive-compulsive cleaning routine. It made sense because he had demonstrated other repetitive behaviors that ft within an OCD framework (e.g., straightening and organizing behaviors). Dean spent time in therapy discussing his routine in the shower; even acting it out while being timed. Upon further assessment, it was discovered that Dean was simply losing track of time in the shower, “zoning out” as he enjoyed the feeling of the warm water and satisfaction of systematically and repetitively washing each part of his body. He decided to try a timer to help him stay on track in the shower. His parents said that they would be satisfed if Dean were able to get his time in the shower down to 30 minutes, so the timer was set to 25 minutes in order to give Dean a 5-minute bufer before having to end his shower. Despite the addition of the shower timer, Dean continued to spend more than 60 minutes cleaning himself and now was becoming increasingly irritated when his parents knocked on the bathroom door at the 30 minute mark. He reported that he was now feeling “rushed” and did not feel satisfed that he had gotten clean when the shower was over. The shower timer went unnoticed until it sounded at the 25 minute mark, making Dean anxious and less focused on completing his cleaning routine. Something had to be done that would help Dean experience the relaxing efects of the shower that he appreciated so much while still keeping him on track to fnish after 30 minutes. To accomplish this, Dean would need to be both cognizant of the time and engaged in the act of showering. It was time to try leveraging Dean’s interest in video games. When asked what his shower would look like if it was a video game, Dean invariably said “Super Mario Bros.,” labeling the water as hot lava and bubbles as Oompas and Goombas (enemy characters in the original NES Super Mario Bros. game). Dean described the plumbing in the shower as reminding him of the pipes in Mario that take you to diferent worlds and reported that he often “zoned out” while looking down the drain. He went on to say, “Mario is a part-time plumber you know.” After Dean spent time creating a Super Mario Bros. game out of his shower routine, it was time to decide on the background music. Super Mario Bros. has a substantial collection of music to choose from, ranging from meditative “Sirena Beach” to the more intense “Ground Theme” (fast version). Dean decided that the frst ten minutes of his shower

70

Autism and Video Games (and Anime)

would be the standard “Ground Theme” (slow version) because that is when he is “getting used to the water and choosing products.” The second ten minutes would have the background music that plays when Mario is underwater in the game because “that is when I am under the showerhead the most.” The next fve minutes would have the fast version of the “Ground Theme” because “I will have to start to speed up after 20 minutes if I want to fnish in a half an hour like my parents want me to.” Surprisingly, Dean decided that the fnal fve minutes of his shower soundtrack would be the background music from the original Donkey Kong video game. Dean said that he chose this music because “The last fve-minutes is when I need to be the most focused on getting out of the shower. I will imagine that the showerhead is Donkey Kong and I need to fnish rinsing so that I can knock him of his pedestal. There’s no turning back in Donkey Kong.” Using Dean’s chosen video game music, an mp4 was created for him to turn on upon entering the shower each evening. The music reminded Dean of the images he discussed in therapy and helped him stay on track in the shower while still feeling engaged in the process of getting clean. Dean was able to split his shower routine up into four separate “levels” that each involved diferent tasks. The only way to “win” his gamifed shower was to keep his cleaning routine aligned with the music. Dean started taking showers that lasted EXACTLY 30 minutes, leaving his parents thrilled with his progress and the household water bill much improved.

Gamifying Non-Preferred Activities In addition to being a student, Dean worked in the cafeteria at a large convent. His job responsibilities included picking up dishes after the nuns who lived in the convent fnished eating and bringing them to the kitchen to be cleaned. He hated this part of his job because “It never feels done. As soon as I clean up the plates at one table there are new ones left at the table that I just cleaned.” Dean was struggling to keep up with his responsibilities because “When I get bored, I can’t focus.” Using video game music to help him remember imagery worked so well for him when he was trying to cut down on his time in the shower that he decided to try it for work as well. When asked what the convent would look like if it were a video game, Dean was quick to reply with “Pac-Man.” He said that the dishes reminded him of the pellets Pac-Man gobbles up and that the nuns reminded him of ghosts because of “the way they all dress the same.” When the bell rang that announced that the meal had ended for one group of nuns and it was time for another group of nuns to enter the cafeteria, Dean said it reminded him of when the ghosts turn invisible

Autism and Video Games (and Anime)

71

in Pac-Man and he has a short amount of time to gobble up as many pellets as he can before they can get him again. He set missions in therapy to try to use this imagery at work to “clear the level (quadrant of the cafeteria)” as quickly and strategically as possible between meal shifts, ultimately improving his work performance and satisfaction so much that he was asked to help cook lunch for the nuns; a “huge promotion!” Dean’s Video Game–Themed Treatment Plan

Table 6.1 Dean’s video game–themed treatment plan

Environment/setting Main characters Video game name (Real name)

Soundtrack

Tools needed

How to earn points

Level won when

Level One

Level Two

Super Mario Bros. and Donkey Kong (shower) 1. Mario (Dean) 2. Oompas (soap bubbles) 3. Goombas (shampoo bubbles) 4. Hot lava (water) 5. Donkey Kong (finishing) 1. First ten minutes (“Ground Theme”; slow version) 2. Second ten minutes (“Underwater Theme”) 3. Next five minutes (“Ground Theme”; fast version) 4. Final five minutes (Donkey Kong) 1. Mushroom power-ups (soap) 2. Collecting coins (keep moving) 3. Flame ball (washcloth) 1 point = wash hair 2 points = wash and rinse body 3 points = finish before soundtrack ends Dean steps out of shower before soundtrack ends

Pac-Man (work at the Mother House) 1. Pac-Man (Dean) 2. Pellets (plates) 3. Ghosts (nuns)

Pac-Man Theme

1. Cherry (being fast) 2. Strawberry (staying relaxed and focused) 3. Key (mindfulness) 1 point for each table cleared

40 points earned (the typical number of tables cleared during a shift)

72

Autism and Video Games (and Anime)

Video Game Controller Imagery Another technique that can be helpful when helping many gamers, including those with ASD who often struggle with multistep directions (Wilkinson  & Rosenquist, 2006), with how to remember the steps involved in a particular mission is using video game controller imagery. For some people, using video game controller imagery can be even more helpful than an acronym, like many of those used in CBT (e.g., see RIDE or GAME in Chapter 5). When using this technique, it is important to frst ask the client what platform he/she uses most when gaming because each platform has its own controller, and it is important that the client is familiar with the controller image being used. A  good next step is to ask the client to draw the controller so that a “Game Controller User’s Manual” can be created to identify what action correlates with each button on the controller (see the appendix for game controller worksheets that can also be used). The Case of Nick “Nick” is one good example of the video game controller technique working well. Nick was a smart young man (13-years-old) with ASD who often struggled with social anxiety and remembering the steps involved with his routine at school. He would also commonly lose books, gym clothes, and other items because, “I got distracted because my routine was thrown of and I was trying to fgure out what to do next.” Nick’s preferred video game platform was the Sony Xbox, so he used the Xbox controller when thinking about what buttons he would need to press in order to accomplish key actions throughout the school day. Nick was proud of his gaming prowess and felt confdent that he could remember what he needed to do during the school day if the steps correlated with pressing buttons on an Xbox controller because “I don’t even need to think about what buttons to press when I’m playing Call of Duty [Nick’s favorite game].” His intuition was correct. The game controller pictured in Figure  6.1 depicts Nick’s choices when determining which buttons to press and in which order. His explanation for each decision provided great insight into how he felt about each action and the context involved. For example, when asked why Nick chose to press the left stick twice, followed by the right stick once to remember how to manage social anxiety he said, “Because pressing the left stick is what you do in Call of Duty when you want to take a deep

Autism and Video Games (and Anime)

73

breath before using a sniper rife. Pressing the right stick is what you do to open doors.” It should be noted that Nick’s preferred strategy for managing social anxiety is the physiological sigh, an evidencedbased breathing technique that activates the parasympathetic nervous system to help moderate the release of adrenaline (Vlemincx et  al., 2010). The technique involves inhaling through the nose twice during the same breath, then extending the exhale through the mouth. Nick would use the physiological sigh technique three times in succession to lower his stress, so he imagined himself pressing the left stick twice, then the right stick once, three times in a row. When all was said and done Nick used Call of Duty controls as inspiration to remember all the actions he was working on at school. For those reading this book who are familiar with Call of Duty, the decisions made in Nick’s controller are probably not surprising. For example, he used LT, then Y to remember to pick his books up after class. This is the same pattern of buttons that are pressed in Call of Duty if a player wants to look down, then reload. Nick’s Controller

Figure 6.1 • • • • • •

Left stick move, then B (Get off the bus and transition to the school day)

Left stick move, then Y (Transition between classes) X and D-pad down (Ground self in class) Press left stick twice, then right stick once (Manage social anxiety) LT, then Y (Remember books and other belongings) LB (Write down homework)

74

Autism and Video Games (and Anime)

Using Avatars to Diagnose and Understand a Person’s Relationship With Autism As with repetitive behaviors in OCD, avatars can be a useful tool for assessing and understanding a person’s relationship with ASD. The case of the Claws discussed in Chapters 3 and 5 is a good example of a clientcreated character to represent a problem because it appears ferce, scary, and includes features that are symbolic of what it was created to symbolize. In ASD, the “problem” can be more unclear, especially when considering how a person identifes with it. For this reason, problembased characters are often replaced by avatars representing a more egosyntonic relationship for people with ASD. For example, when creating “problem-based imps” for the video game MindGamers in School described earlier in this book, some people (especially those meeting criteria for ASD) created characters that looked like a rebel or other humanoid that could be a “good friend who is a bad infuence.” When created to represent a repetitive behavior, this type of character can often suggest a more pleasure-seeking and internalized process, such as in many preoccupations or perseverative behavior. Once again, this is in contrast to the monsters and other ferce creatures that many young people with OCD will create in therapy. Building on externalizing the problem with avatar creation can also ofer many therapeutic opportunities to learn about young people with autism’s perspectives on things, such as how they see themselves and how they think other people see them. This is valuable because many people with ASD struggle with perspective-taking (Atherton et  al., 2019). There are many video games that include character creators that lend themselves well to creating avatars representing the self, but The Sims is probably the most widely recognized. The Sims also provides options related to personality traits and interests that can be especially useful for examining perspective-taking with a client with ASD. In the following case of “Cassy,” an example of how to use client-created characters to represent the “ideal” and “disowned” self is provided, yet another way that character creation can shed light on a person’s relationship with the label, herself, and those around her. Anime and the Case of Cassy For reasons that still have not been adequately researched, many of the females with ASD who contributed to the ideas in this book are especially interested in anime. In fact, whereas most of the males with ASD identifed as gamers, most of the females with ASD identifed as “Otakus,” the word used by many to describe someone who is passionate about anime. Cassy was not an exception in this regard. Cassy was a

Autism and Video Games (and Anime)

75

14-year-old young woman diagnosed with anxiety and depression (later ASD) upon referral. She was also a talented artist and anime enthusiast who used anime in therapy in many of the same ways that others have used video games. Cassy attended each appointment with a pad of drawing paper and pencil that she would be drawing intricate anime characters on. She reported that she created these characters in her mind and talked about them as if they were real people. Cassy struggled with making friends locally but had many online friendships that she valued greatly. All these online friendships were with people from other states and were made through their mutual love of the anime series Reborn. When telling a story, it was often difcult to determine if Cassy was talking about one of her online friends, a character from Reborn, or an anime character that she had created in her mind and on her drawing pad. This uncertainty often lasted several minutes, as Cassy had created highly complicated backstories and personalities for each of her characters. At her frst therapy appointment, Cassy and her mother reported that she was diagnosed by her psychiatrist with anxiety and depression. Autism had been discussed but ruled out because “She can’t possibly have autism because she wants friends.” Despite wanting more in-person friends, Cassy struggled to connect with others at her school because “all any of those girls want to talk about is boys and makeup. They don’t even know that Reborn exists!” The idea of autism was dropped after that and not discussed again until she was referred for psychotherapy. When asked which anime character Cassy had either created or is on Reborn that reminded her of the things she wanted to change about herself, she fipped through her thick sketch pad and pointed to a character that she named Umi. Umi (pictured to the left in Fig. 6.2) was a “weird girl who hates herself and worries about what everyone else thinks about her.” Umi’s expression was of disgust, and she had horns and four octopuslike arms with three long nails on the end of each. When asked which anime character Cassy had either created or is on Reborn that reminded her of the things that she was most proud of, she once again fipped through her sketch pad and pointed to a character from Reborn named Chrome who she had drawn. Chrome (pictured below to the right in Fig. 6.2) was the star of Reborn. A former nerd and self-confessed “weird girl,” Chrome had a moment in the show when she came out of her shell and stopped worrying about what other people thought. She was well-liked and respected for being diferent. In the image that Cassy had drawn, Chrome’s expression was one of joy, and both of her two personas from the TV show were depicted; a semi-superhero with an eye patch, as well as a regular teenage girl.

76

Autism and Video Games (and Anime)

Figure 6.2 Cassy’s drawings

At her second appointment, the DSM was used, with Cassy’s help, to diagnose Umi. The choices were those that Cassy’s psychiatrist had provided (i.e., anxiety and depression) and one that had been ruled out long ago and never discussed since, Asperger syndrome (now “high functioning” ASD). The results were clear; Cassy was certain that Umi met criteria for Asperger’s. The diagnosis was confrmed by having Cassy complete the Gilliam Autism Rating Scale (GARS) for Umi. As one can imagine, it was not terribly difcult to frame a discussion around Cassy’s own possible relationship to ASD, a realization that her mother absorbed with “tears of happiness” because “I have always felt this way, but no one ever agreed with me, so I gave up.” Cassy too was “relieved” at the decision to start using ASD, rather than anxiety and depression, to explain some of the constraints to her goals (e.g., making friends). She reported that many of her online friends had confded in her that they were autistic, something Cassy had grown to admire about them because “they are such friendly people, and I was told that I can’t have autism if I want friends.” Cassy continued to use Umi and Chrome in therapy for years after frst introducing them. Interestingly, Umi actually started to come out of her shell a little during that time, even befriending Chrome in one of Cassy’s fan fction stories. At the same time, Cassy was growing more comfortable with ASD as part of her chosen identity, connecting with others on the spectrum and meeting up with them (in person!) to attend

Autism and Video Games (and Anime)

77

anime conventions. She would often attend these conventions dressed as Chrome but kept a drawing of Umi in her pocket to remind her that she can choose which version of herself she wants to be.

Common Questions and Answers Question Are online friends “real” friends?

Answer If the COVID-19 pandemic has taught us anything it is that our connections with people are both important and can be efectively facilitated by technology when in-person contact is not an option. Cassy’s story illustrates how “real” online friends can be, and for many people with ASD this is often as close to “real” as they are ready for (or prefer).

Question What about teaching social skills to people with ASD? Can video games be helpful for teaching social skills too?

Answer Absolutely, especially in groups (see Chapter 7). In particular, co-op video games are a wonderful way to encourage cooperation and other skills important to making and sustaining meaningful relationships. Co-op video games allow multiple players to play at the same time in cooperation to achieve a particular goal. Several examples of co-op games are provided in Part 2 of this book, (e.g., Portal 2 and Lego games) including ideas for using them to teach social skills. There are also a handful of games and experiences that were created specifcally for the purpose of teaching social skills to people with ASD. The Social Express (socialexpress.com) is one popular example. Another example is Mightier (mightier.com), which was developed to help children with ASD learn to manage their emotions, including in social situations (Vaudruiel et al., 2017). Virtual reality provides some unique and powerful opportunities for teaching social skills. For example, virtual groups and practice conversations with other’s avatars in VR can provide a safe laboratory for experimenting with new ways of interacting. More ideas for how to use VR to teach social skills can be found in Chapter 10.

78

Autism and Video Games (and Anime)

Question But I thought people with ASD think in concrete terms and are not good at interpreting metaphors?

Answer One common misconception about people with ASD is that they are not good at thinking metaphorically. In actuality, many people with ASD, including those who contributed to the ideas in this book, are exceptional at thinking metaphorically, especially when those metaphors stem from something they are passionate about.

Question Are there any other ways that video games can be helpful when working with people with ASD?

Answer The ideas in this book are just the tip of the iceberg when it comes to the potential use of video games to help people with ASD. Readers of this book are encouraged to follow the research, as new and exciting studies are currently being conducted and published in high-impact, peerreviewed journals such as Games for Health and Cyberpsychology. Additional examples of ways to leverage video games when working with people with ASD are provided in Chapters 8 (YouTube videos) and 10 (virtual reality).

Therapist Missions • •

Create your own controller showing what buttons you would press to get through a day. Be prepared to share your controller with clients when pitching the idea to them to create their own in therapy. Consider picking up some anime for the ofce.

References American Psychiatric Association, DSM-5 Task Force. (2013).  Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc. Atherton, G., Lummis, B., Day, S.,  & Cross, L. (2019). What am I  thinking? Perspective-taking from the perspective of adolescents with autism.  Autism, 23(5), 1186–1200.

Autism and Video Games (and Anime)

79

Gallup, J., & Serianni, B. (2017). Developing Friendships and an awareness of emotions using video games: Perceptions of four young adults with autism. Education and Training in Autism and Developmental Disabilities, 52(2), 120–131. Jiménez-Muñoz, L., Peñuelas-Calvo, I., Calvo-Rivera, P., Díaz-Oliván, I., Moreno, M., Baca-García, E.,  & Porras-Segovia, A. (2021). Video games for the treatment of autism spectrum disorder: A systematic review. Journal of Autism and Developmental Disorders. Advance online publication. Lane, R.,  & Radesky, J. (2019). Digital media and autism spectrum disorders: Review of evidence, theoretical concerns, and opportunities for intervention. Journal of Developmental and Behavioral Pediatrics, 40(5), 364–368. Loomes, R., Hull, L., & Mandy, W. (2017). What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 466–474. MacMullin, J., Lunsky, Y., & Weiss, J. (2016). Plugged in: Electronics use in youth and young adults with autism spectrum disorder. Autism, 20(1), 45–54. Mazurek, M., Shattuck, P., Wagner, M., et al. (2012). Prevalence and correlates of screen-based media use among youths with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(8), 1757–1767. Mazurek, M., & Wenstrup, C. (2013). Television, video game and social media use among children with ASD and typically developing siblings.  Journal of Autism and Developmental Disorders, 43(6), 1258–1271. Pluhar, E., Kavanaugh, J., Levinson, J., & Rich, M. (2019). Problematic interactive media use in teens: Comorbidities, assessment, and treatment. Psychology Research and Behavior Management, 12, Article 447–455. Rice, R., Douthit, K., & Williams, T. (2014). The repetitive behavior spectrum: From helpful to harmful. Autonomy, the Critical Journal of Interdisciplinary Autism Studies, 1(2). Vaudruiel, C., Chasser, Y., Hoover, C., Jacobs, L., & Hirshfeld-Becker, D. (2017). RAGE control: Teaching emotional self-regulation through video game play. Poster presented at the Annual Conference of the American Association of Child and Adolescent Psychiatrists. Vlemincx, E., Taelman, J., Van Diest, I., & Van den Bergh, O. (2010). Take a deep breath: The relief efect of spontaneous and instructed sighs.  Physiology  & Behavior, 101(1), 67–73. Wilkinson, K., & Rosenquist, C. (2006). Demonstration of a method for assessing semantic organization and category membership in individuals with autism spectrum disorders and receptive vocabulary limitations.  AAC: Augmentative and Alternative Communication, 22(4), 242–257. Willoughby, T. (2008). A short-term longitudinal study of internet and computer game use by adolescent boys and girls: Prevalence, frequency of use, and psychosocial predictors. Developmental Psychology, 44(1), 195.

Chapter 7

Gamer Groups

The current chapter will focus on using video games in group work, especially as it pertains to teaching social skills, envisioning new futures, and providing opportunities for young people to work on their templates for interacting with others. Many of the young people who contributed to the ideas in this book have attended gamer groups using the curriculum proposed later in this chapter and have infuenced its evolution since the groups frst started running in 2014. The goal of this chapter is to introduce the idea of using video games in group work with young people, including for social skills, support, and psychotherapy. A  curriculum mental health professionals can use to jumpstart their own evolutionary process related to using video games in group therapy for young people is also provided, along with some important information related to developmental, gender, and other considerations.

Why Gamer Group? There are many circumstances where group therapy can be more helpful than individual therapy. For example, group therapy is the primary modality for substance use treatment and dialectical behavior therapy. Many of the ideas presented in the current chapter were originally conceived of for the purpose of helping young gamers practice skills needed for socialization and self-regulation, but they could easily be modifed to help other populations. Although there is still limited research substantiating the value of using video games in group therapy, the studies that do exist are promising. For example, Benatov et al. (2021) found that Jewish-Israeli and Palestinian-Israeli school-age children who used a cooperative video game as part of a regular group experience showed reduced intergroup bias, including reduced stereotypical views, negative emotions, and discriminatory tendencies toward members of the other ethnic group. These efects remained six months after termination of the program. DOI: 10.4324/9781003222132-7

Gamer Groups

81

Now that video games are among the most popular form of interactive media worldwide and are already infuencing social interactions for young people (e.g., Verheijen et  al., 2020), using them in group therapy for young people is a natural progression from using art and other modalities (e.g., Epp, 2008). One group therapy model using virtual reality (VR) and serious gaming was suggested by Henry-Ducrocq (2011) and implemented with teenage gamers. The intervention promoted learning related to issues such as social roles and identity, in addition to connecting individuals to others within the virtual space. This model suggests the adaptability of pre-existing video games and virtual realities to therapeutic “mods” which may have the potential to be useful and efective interventions. Three common types of groups for young people that lend themselves well to using video games are described next. Video Games in Social Skills Groups Many of the young people who have participated in gamer groups since their origin in 2014 report that they have few, if any, in-person friends; instead, they choose to spend their time playing video games with people from around the world online. Although these connections did have great value in their lives, opportunities to practice many important social skills were often absent in these relationships. Powerful experiences and connections are often made in video games that involve role playing, such as in the popular game World of Warcraft. According to Jordan (2014), individuals build connections and often friendships through these relational video games. In some cases, these friendships become some of the most meaningful and predictable experiences in their lives. The demand for young people to learn social skills continues to increase, while options for learning these skills remain limited. One contributing factor to this issue is the increasing prevalence of autism spectrum disorder (ASD), which is now estimated to be 1 in 44 children in the U.S. based on current statistics from the Center for Disease Control and Prevention (cdc.gov). Developmentally, game play facilitates social interactions and the development of social inclusion skills, including for young people with ASD (Giannopulu & Pradel, 2010). In addition, Baker et al. (1998) found that developing activities using an individual’s restricted interests resulted in intrinsically motivating opportunities for social engagement among individuals with ASD. Some of the best video games for learning social skills are co-op games. Co-op games are games where multiple players can play at the same time in a collaborative manner to achieve a common goal. The Lego series of games and Rayman ofer several options in this category. Portal 2 is a favorite choice for many gamers in the 12–17 age range. Halo 4 is a

82

Gamer Groups

clear favorite among many older group members (16 years and older), and although it is a frst-person shooter, it involves no violence toward humans or graphic images that might be disturbing. From the mental health provider’s perspective, the goal in social skills–focused gamer groups is to track group members’ behavior (both in and outside the game) as a way to enhance the likelihood for teachable moments and to provide a mirror for group members to examine their behavior. Gamer groups focused on social skills development often have weekly or monthly “themes” (e.g., teamwork, respect, socialization, cooperation, respect). For gamer groups focused on social skills development, these themes are often discussed at the beginning of the group by chatting about how group members can demonstrate them during their time together. Often, group members will reference themes by saying “that was socialization” or “that doesn’t sound respectful.” In this way, the inclusion of these themes has helped many group members become more confdent in advocating for themselves or others in the group. One example provided by a counseling intern running a gamer group involved a new gamer who did not know much about games and decided he wanted to play Super Smash Bros. with the other group members. Another group member noticed the new gamer struggling and instead of getting upset with him said, “Hey, why don’t you try this move” and continued to do so after every match to help him learn how to play the game. The therapists praised the group members for their cooperation and used the group’s successes as a way to reauthor narratives during times of future confict. Video Games in Support Groups One of the reasons so many young people opt to stay at home and play games with others online is because it feels safe and predictable. For many young people with mental illness, the prospect of exposing their insecurities to others in person is far too big a risk to take unless there is an incentive. Video games can often provide this incentive for young people who are comforted by the knowledge that “at least I  can talk about video games with them.” Once there, the gamer group often provides a community of support for its members. Many of the young people who contributed to the ideas in this book were frst connected to the concept of gaming in therapy as part of their participation in a support group assembled for transition-age youth. Most of the participants in this group had either a diagnosis of ASD or other issues impacting their ability to transition from the relative predictability of high school to the more uncertain college or work experience. The support group (self-named “The MindFit Experts”) had less structure than social skills groups, instead using weekly themes and

Gamer Groups

83

opportunities to consult on games for health. For example, the MindFit Experts contributed heavily to the next chapter in this book (Chapter 8), focusing on the use of YouTube and Let’s Plays in psychotherapy. Specifcally, they personally reached out to YouTubers to ask them about videos that include themes related to mental health. They then watched content together, discussed it, and screened it for this book, assembling a list of Let’s Plays with time stamps. Like many support groups, the MindFit Experts regularly welcome new members and leave space for discussing life experiences. When it goes well, participants use the group to build the confdence they need to take the next steps in their lives. For many people, their experience “consulting” on the use of video games in psychotherapy ignited a fre in them to pursue further training or a career in games for health. Relationships are also made in group that often extend past the boundaries of the group’s scheduled time. The process of planning for group is coconstructed, with group participants having at least as much a role in determining what the group will focus on next as the mental health provider. Having this purpose brings them together. They are “appreciative” (Madsen, 2007) allies for each other. Selecting video games for gamer groups focused on providing support to young people exploring issues around identity and meaning is less straightforward than other types of groups, but there are some guidelines that can be helpful. For example, as with many groups, at the beginning of a support-focused gamer group it can be helpful to establish rules around what types of video games will be played. Even older gamer groups tend to have important conversations about things like violence and competition during these discussions. Often, allowing for each group member to select one of the video games played by the group each session can provide additional opportunities for gamers to express themselves and receive approval from others in the group, promoting the group dynamic. Video Games in Psychotherapy Groups Psychotherapy groups typically have a specifc purpose and often focus on a particular diagnosis. For this reason, choosing video games that can be useful for psychotherapy groups is largely dependent on the specifc purpose of the group. Generally speaking, games that include a variety of potential metaphors representing constraints to progress are especially useful in psychotherapy groups because they can be used to help externalize issues like anxiety, depression, or other common experiences for young people. Superhero games and Pokémon are great examples of video games with these types of metaphors because they include several characters that might be interpreted as both positive and negative by diferent players.

84

Gamer Groups

Using YouTube videos (e.g., Let’s Plays) as part of psychotherapy groups can often be a good way to make the conversation about mental illness easier for participants. Chapter 8 in this book provides examples of some of these videos and ideas for how to approach their use in therapy as a way to nonjudgmentally discuss mental illness with gamer clients. New content is being created daily and uploaded to YouTube, so asking group members for ideas of videos that they have seen recently (i.e., discussing the diagnosis or problem being addressed in the group) can also contribute to a collaborative environment that values the strengths and interests of its participants.

One Approach to Gamer Groups One approach for using video games in group therapy for young people involves a strategic efort to match games with skills and lessons being focused on to encourage an enhanced level of engagement for participants. One example of a curriculum that follows this approach is provided in this section and has been implemented and refned since 2014, including through a small, unpublished institutional review board (IRB)–approved study in 2014 examining the efectiveness of a ten-week group curriculum integrating video games with narrative and cognitivebehavioral concepts. Based on the group types discussed previously in this chapter, the curriculum described in the next section might be best classifed as a psychotherapy group, though it provided many benefts pertaining to social skills and support as well. The 2014 gamer group study involved the evaluation of three separate groups, all using a modifed form of the same curriculum. The frst two groups included six 12–14-year-old males and six 18–26-year-old males, respectively. Qualitative data was collected by reviewing weekly progress notes (e.g., methods that worked well, did not work, problems and successes) and individual milestones (e.g., making a friend, working collaboratively with peers, asserting themselves). Qualitative data for these groups was also recorded each week by a student researcher from the Netherlands whose time and travel were being supported by a grant. The student researcher collected and coded feldnotes, as well as conducted participant interviews. The results of these frst two gamer groups were highly positive and resulted in more refnements and research involving a third group, described next. Referrals for the third 2014 gamer group were made by mental health providers for children ages 9–12 who presented with concerns around socialization and anxiety. Eight individuals were referred, with seven providing informed consent to enroll and participate. Pre and post data was collected using the Communication Use and Social Skills domains of the Adaptive Behavior Assessment System (ABAS) (Harrison & Oakland,

Gamer Groups

85

2000). Specifcally, items 7–24 under communication use were scored, and all items under social skills were scored. The video game consoles used included two Nintendo Wiis, a GameCube, and an Xbox 360, each set up on separate screens in separate spaces. For the sessions when the game Minecraft was used, a laptop computer or an iPad was provided to group members who did not have their own. Group members were encouraged to bring their own devices as long as they were able to participate fully in group activities, including video games played. The Curriculum The third gamer group met one day a week for one and a half hours for ten weeks. Prior to the start of group, parents of the group participants were given a letter of introduction and informed consent explaining the group and the research. Upon consent, parents were given the parent form of the ABAS. The ABAS was collected at the frst session, and parents were told there would be an additional ABAS to be completed prior to the tenth session. The gamer group curriculum integrated specifc narrative therapy concepts into each week, with odd weeks focusing on learning new skills and even weeks focused on practicing those skills. Skills were taught using specifc video games. For example, gamers may identify “anxiety” as their problem and then create a “monster” in a video game that represents and externalizes the problem. On the following (even) week, gamers might introduce their problem-based characters and collaboratively build cages in Minecraft to hold their respective monsters. The weekly curriculum used for the group is provided next. Each group was ended with a few unfnished sentences intended to reinforce lessons. Unfnished sentences are an approach to values clarifcation in counseling (Grumet & Fitzpatrick, 2016; Simon & Olds, 1976; Kirschenbaum, 2013) and were answered by each group member (unless they chose to pass) and counseling intern. Sessions ended with each group member placing his or her fst in a circle and shouting, “Gamers Out!” Week One Each group member completed a personal strengths assessment during the frst week of gamer group. First, group members were instructed to create “power cards” representing their strengths (e.g., smart, funny, kind). More details and an example of power cards are provided in Chapter  3. Then, group members used the Nintendo Wii to create a “Mii” representing their “preferred self” or “how they think other

86

Gamer Groups

people see them on a good day.” While group members created their Mii, the graduate-level counseling interns facilitating the group asked questions such as “If you had a super power in a video game what might that be?” and “How might you use that in real life?” and “What are some strengths that help you battle the hard stuf in life?” Finally, in week one, group members created a “gamer tag”; a code name they chose to be called by for the remaining weeks of gamer group. Group members were instructed to keep their power cards and gamer tags and wear them for the remaining weeks of gamer group. The unfnished sentences for week one were: • •

This is my Mii. I chose to make it this way because_______. I was my best self tonight when_______.

Week Two The goal was to reinforce identifed strengths from the previous week with a group-based activity. Minecraft was chosen for this activity, in which the group was split into two teams and given the mission to create a structure together that: 1) represents the strengths of their team and 2) is welcoming and easy to use by visitors (the other team). Group members each had their own device for this activity and were connected on a shared server that allowed them to exist in the same Minecraft world at the same time. While the group members were busy building in Minecraft, counseling interns asked questions such as “What strengths show up when you work together as a team?” and “How did your strengths help you build that?” The unfnished sentences for week two were: • • •

One thing I added to the “Ideal Gamer Group World” was_______ because_______. One strength I demonstrated in group tonight was_______. One thing I learned in group tonight is_______.

Week Three The goal was externalization; group members were instructed to create a monster on the iPad that represented something they wanted to change or work on. The apps Monster Maker and Blob Monsters were chosen for this task. As a reminder, externalization is the process used in some approaches to psychotherapy (e.g., CBT and NT) to help people see themselves as separate from the problem, thereby allowing for safer and more productive conversations about the problem and its role in the person’s life (Madsen, 2007). After creating their monsters, group

Gamer Groups

87

members gathered in a circle and presented on them to the full group. In subsequent iterations of gamer group, group members were put in pairs to work on their monsters, and the other person in each pair presented on his or her partner’s monster. The unfnished sentences for week three were: • • •

I named my monster _______ because_______. One thing I learned in group tonight is_______. I was my best self tonight when_______.

Week Four The goal was to integrate the externalized character from the previous week into the collaboratively created Minecraft world from week two. Group members once again used their own devices to work together on the same shared Minecraft server used in week two. Group members were challenged to create a space in the Minecraft world for their problembased characters (e.g., dungeons, traps, cages, etc.). Counseling interns tracked group member behaviors and encouraged them to work together to complete their monster’s space. The unfnished sentences for week four were: • • •

This is the space I created for (monster name). I made it this way because_______. One thing I learned in group tonight is_______. I was my best self tonight when_______.

Week Five The goal was to help group members consider a future focus and how they navigate obstacles. To accomplish this goal, group members were placed in two groups that rotated between two stations. The frst station played a game called Portal 2 on the Xbox 360, in which they would need to work together as robots to solve puzzles in a futuristic obstacle course. In the second station, group members played Mario Kart on the Wii while counseling interns watched and tracked their progress in the game, especially as it pertained to group members’ coping with obstacles in the game (e.g., “You really saw that turtle shell coming from a mile away!”). The unfnished sentences for week fve were: • • •

My favorite course in Mario Kart is_______ because_______. One thing I learned tonight was_______. I was my best self tonight when_______.

88

Gamer Groups

Week Six The goal was to integrate the idea of obstacles (i.e., barriers to success) into a group activity in Minecraft. Group members were placed in two smaller groups and given the challenge to build an obstacle course for the other small group to get through in their shared Minecraft world. Each obstacle was supposed to represent a real-life obstacle. Counseling interns encouraged group members to work together and use their strengths to get through the obstacle course created for them by the other small group. The unfnished sentences for week six were: • • •

My favorite obstacle our small group made was_______ because _______. My favorite obstacle the other small group made was_______ because_______. I was my best self tonight when_______.

Week Seven The goal was to begin the process of deconstruction by supporting group members in examining the relationship between themselves and their previously identifed “monster.” Group members were split into two stations, each focusing on a similar task. Station one used the Wii to play Crash of the Titans, and station two played Pokémon, also on the Wii. Counselors at both stations asked questions such as “How is your real-life monster similar or diferent from the ones in the game?” and “What would it look like if your monster was in this game?” Unfnished sentences for week seven were: • • •

The most difcult monster (or Pokémon) to fght in the games we played today was_______ because_______. One thing my monster has made it harder for me to do is_______. I was my best self tonight when_______.

Week Eight The goal was to continue supporting group members to engage in discussions around game-based and real-life obstacles, as well as the tools and powers needed to overcome them. Each gamer created their own individual obstacle course on paper that included several layers: 1) to identify an obstacle in a game (e.g., a bomb), 2) to identify what power or tool might be used to overcome that obstacle in real life (e.g., creativity), and 3) to identify how that obstacle may apply to a

Gamer Groups

89

real-life situation (e.g., bullies at school). Unfnished sentences for week eight were: • • •

My favorite game-based power is_______ because_______. One time I overcame an obstacle was_______ by_______. I was my best self tonight when_______.

Week Nine The goal was to support the process of reauthoring. The two games used for this process were Marvel Superheroes for the Xbox 360, and Mario Galaxy for the Wii. Counselors working with both groups focused on identifying successes in the game and patterns of game play, such as “You are a person of action!” and “You help your teammate when they need it!” Unfnished sentences for week nine were: • • •

My favorite superhero is_______ because_______. It was really cool when_______ (other group member name) did________ (something in the game that impressed the group member). I was my best self tonight when_______.

Week Ten The goal was to celebrate the successes of the group members. Each group member received a “Certifcate of Achievement” that recognized notable accomplishments made over the ten weeks of gamer group. Group members played Mario Party on the Wii, allowing them to play together and celebrate what they learned about themselves and each other. Unfnished sentences for week ten were: • • •

My favorite part about gamer group was_______. I was my best self in gamer group when_______. One thing I will take with me from gamer group is_______.

Results, Discussion, and Future Directions Although the 2014 gamer group study was small and sheds minimal light on the curriculum’s actual efcacy, it does pave the way for larger studies and modifcations. Since the 2014 gamer group study, the curriculum has been used again and again with success, making some changes to video games based on the age of group members. It should be noted that group member ABAS scores in the 2014 gamer group study increased by an average of 7 and 1.6 points on the communication use and social skills

90

Gamer Groups

domains, respectively, when pre- and posttest scores were compared. The qualitative analysis also suggested that the goals of the curriculum were achieved, based on the themes that emerged in each session.

Common Questions and Answers Question How can the group curriculum provided in this chapter be modifed for diferent age groups?

Answer The simple answer is game selection, but there are other considerations as well. For example, many older (e.g., late teen) gamers may prefer The Sims to the Nintendo Wii to create avatars representing their best self. More violent themes tend to work their way into older gamer groups as well, though eforts are made to limit violence toward humans and excessively graphic images (e.g., Grand Theft Auto). Older gamer groups also tend to be more receptive to processing in the group and can tolerate longer periods of time answering unfnished sentences.

Question How do you know if someone is a good ft for a group?

Answer As with organizing any group, the screening process is essential to maximizing the potential of a gamer group. The age groups 9–12, 13–16, and 17–21 tend to work well together, though in many cases (e.g., groups focusing on the needs of gamers with ASD) age is less important than the types of games being played and used to promote the purpose of the group. Gender can also be an important consideration when organizing gamer groups, as there tend to be stereotypes in the gamer community that may need to be addressed (Morgenroth et al., 2020).

Question What about virtual reality in group therapy?

Answer The potential for virtual reality in group therapy is just beginning to be realized. There are already groups being run completely in VR, making

Gamer Groups

91

accessibility less of an issue when geographic or other barriers related to getting to the therapy ofce are present. More on VR in groups can be found in Chapter 10 of this book.

Question How much structure should a gamer group have?

Answer There is a fne line between too much and too little structure when running a gamer group. Often, the main allure of the group for most of the participants is the prospect of playing video games, so adding too many activities that distract from that does not go over well. At the same time, once several young people are given the opportunity to play video games with little structure, it is difcult to add that structure later on. The amount of structure for a gamer group also depends on factors such as age, goals, and stage of the group. For example, younger gamer groups often require more structure than older gamer groups, and psychotherapy groups require more structure than support groups. Likewise, the amount of time a young person has been in gamer group can infuence the amount of structure to provide. Since starting gamer groups in 2014 there are now three levels (Gamer Group 101, Gamer Group, and Gamer Club), each ofering diferent levels of structure.

Therapist Missions •

Start planning your gamer group!

References Baker, M., Koegel, R.,  & Koegel, L. (1998). Increasing the social behavior of young children with autism using their obsessive behaviors. Journal of the Association for Persons with Severe Handicaps, 23(4), 300–308. Benatov, J., Berger, R., & Tadmor, C. (2021). Gaming for peace: Virtual contact through cooperative video gaming increases children’s intergroup tolerance in the context of the Israeli—Palestinian confict. Journal of Experimental Social Psychology, 92, Article 104065. Epp, K. (2008). Outcome-based evaluation of a social skills program using art therapy and group therapy for children on the autism spectrum. Children and Schools, 30, 1. Giannopulu, I., & Pradel, G. (2010). Multimodal interactions in free game play of children with autism and a mobile toy robot. Journal of Neuro Rehabilitation, 27, 305–311.

92

Gamer Groups

Grumet, R.,  & Fitzpatrick, M. (2016). A  case for integrating values clarifcation work into cognitive behavioral therapy for social anxiety disorder. Journal of Psychotherapy Integration, 26(1), 11–21. Harrison, P., & Oakland, T. (2000). Adaptive behavior assessment system. Harcourt Assessment. Henry-Ducrocq, S. (2011). The therapeutic LAN: A group intervention method involving network video game as social simulator. Journal of CyberTherapy and Rehabilitation, 4(2), 242. Jordan, N. (2014). World of warcraft: A  family therapist’s journey into scapegoated culture. The Qualitative Report, 31, 11. Kirschenbaum, H. (2013). Values clarifcation in counseling and psychotherapy: Practical strategies for individual and group settings. Oxford University Press. Madsen, W. (2007). Collaborative therapy with multi-stressed families. Guilford Press. Morgenroth, T., Stratemeyer, M., & Paaßen, B. (2020). The gendered nature and malleability of gamer stereotypes. Cyberpsychology, Behavior, and Social Networking, 23(8), 557–561. Simon, S., & Olds, S. (1976). Helping your child learn right from wrong: A guide to values clarifcation. McGraw-Hill. Verheijen, G., Burk, W., Stoltz, S., van den Berg, Y., & Cillessen, A. (2020). Associations between diferent aspects of  video game play behavior and adolescent adjustment. Journal of Media Psychology: Theories, Methods, and Applications, 32(1), 27–39.

Chapter 8

YouTube and Let’s Plays in Psychotherapy

YouTube Videos in Mental Health YouTube is among the most infuential online platforms for young people (O’Keefe et al., 2011). It is widely regarded as the most important source of visual entertainment and information in the world. Like with video games, YouTube can be integrated into psychotherapy. For example, YouTube can be used for normalizing, challenging stigma, education, and empowerment (Naslund et al., 2016). YouTube is also being used as a mechanism to provide psychoeducation and has become a mainstream method for information seeking. According to Oliphant (2013), “In 2011, YouTube had more than one trillion views or around 140 views for every person on Earth. The use of YouTube is a political, social, and economic force that is changing how people connect, access, share, and exchange information” (p. 153). In an attempt to cope with or manage mental health concerns, people are turning to YouTube and online sources for support and health information (Oliphant, 2013). Sometimes they seek this support formally through channels and videos focused on issues in mental health, and other times informally through media created by peers or people with similar interests. As a result, social media such as YouTube may play an essential role in educating young people about mental illness. Because YouTube has such an impact, understanding user engagement is essential for contemporary mental health workers. Understanding how users engage with mental health information on YouTube and social media is an important part of the assessment process when using video games in psychotherapy. Research has shown that users perceive personal videos/narratives to be more engaging in terms of interactivity, feedback, and attention (Oliphant, 2013). Studies have also found that individuals with mental illness are turning to YouTube to share about their experiences and seek support (Woo et  al., 2018; Naslund et al., 2014). Posts on popular social media such as Facebook or YouTube can “convey acceptance, hope, validation and illustrate the DOI: 10.4324/9781003222132-8

94

YouTube and Let’s Plays in Psychotherapy

give-and-take nature of connecting with peers online” (Naslund et al., 2016, p. 113). Being able to identify with a social group is believed to increase self-esteem and self-efcacy, as well as reduce uncertainty about oneself (Naslund et al., 2016). YouTube and social media have provided people the opportunity to identify similar others and experience some of the benefts of group participation. It also allows people to remain anonymous and avoid challenges associated with interpersonal defcits, such as non-verbal communication or interpreting social cues (Naslund et  al., 2016). By fnding a safe way to use YouTube in psychotherapy, mental health professionals can create an opportunity for social connection, skill building, psychoeducation, mental illness recovery, and reinforce individual empowerment.

What Is a Let’s Play, and Why Are All My Clients Watching Them? Ask any young person what they watch and there is a high probability that the answer will be YouTube videos. Many young people do not even know what a commercial is! Dig even deeper and you will learn that many of your clients are watching videos of other young people playing video games and providing commentary. A common reaction from mental health professionals when they hear about their young client’s viewing habits is, “Why not play the game yourself?” As it turns out, it is not about the game; it is about the connection that clients are making with the YouTuber. Let’s Plays (LPs) exist where video games and YouTube intersect. LPs are videos of a gamer playing a video game while providing personal commentary. LPs have shown their impact on youth, as evidenced by the massive quantity of streams on YouTube. As a result, they are currently one of the most popular forms of online digital entertainment (Burwell & Miller, 2016). Similar to video games, LPs have the potential to serve many purposes in psychotherapy. For example, they can facilitate psychoeducation, connection building, and grounding (Burwell, 2017). This chapter will explore the potential beneft of LPs in a therapeutic session, especially pertaining to the discussion of difcult topics with otherwise reluctant young people. LPs are a unique hybrid of digital gameplay and video. They are also one of the most popular forms of online digital entertainment. In fact, LPs currently make up over half of the top 100 channels on YouTube (Burwell & Miller, 2016; Burwell, 2017). The content, purpose, and platforms for LPs are as unique as the games themselves. They include gameplay footage accompanied by simultaneous commentary recorded by the player(s), as well as capturing their emotional and

YouTube and Let’s Plays in Psychotherapy

95

physical reactions. The LP’s creator(s) can demonstrate gameplay in various ways. Commentaries are equally broad and may include praise, critique, recommendations, exclamations, questions, instructions, shouts, sighs, whispers, and groans (Burwell, 2017). LP videos address the viewer through the felt presence of the LP creator(s) (Glas, 2015). They are “not about the player’s skills, but his reactions, which become a source of amusement” (Menotti, 2014, p. 89). These reactions make the LP player identifable to the viewer, creating a feeling of connection. The success of the LP phenomenon seems to suggest that the play practices on display in these videos carry meaning to their audiences (Glas, 2015). To the creator, the gameplay is a performance that includes creating a persona, engaging an audience, and making decisions about the narrative as they play (Burwell & Miller, 2016). LPs can both transform meanings and highlight the process of meaningmaking itself. During gameplay, oral commentary (e.g., instructions, questions, profanity, emotion, laughs, shouts, grunts) allows LP creators to communicate what they think, know, and feel about the game (Burwell & Miller, 2016). These expressions are how LPs reveal how gamers create meaning from games. This creation of purpose is what attracts the viewer, making LPs relatable. LPs are unique, imaginative, social ways through which players can obtain gaming capital, share interests, and participate in gaming, dialogue, and learning (Burwell  & Miller, 2016). The eagerness to watch, make, and discuss LPs suggests a want/ desire to communicate with others about an activity that is central to their lives. Creators of LPs often share stories regarding mental illness and other issues pertinent to mental health. This is sometimes done strategically when creating a particular LP, and sometimes more spontaneously as an emergent topic. It is common for the creators of LPs to communicate their connection to games and how they help them cope in life. Inevitably, they also often disclose their diagnoses and share positive stories of recovery. The Case of Abe Abe was a 21-year-old young man who had struggled with relationships, anxiety, and anger since fnishing high school. Upon referral, he reported spending the majority of his time either sleeping or watching YouTube in his parents’ basement. His father described him as living, “the vampire lifestyle.” Abe was struggling with his self-concept and, although he knew that he was probably depressed, he was not ready to talk about depression in the frst person in psychotherapy because his ego was still too fragile to accept yet another label.

96

YouTube and Let’s Plays in Psychotherapy

When asked about his viewing habits at the frst appointment, Abe reported that he watched a pair of YouTubers called the Game Grumps and proceeded to show an example of their work on his phone. “What do you like about the Game Grumps?” I  asked. “They are funny, and I like the way that they think about things,” he answered. Abe then discussed an example of how the Game Grumps “think that people should do the things that they enjoy and that nobody should try to make them mad for that.” “What do you think the Game Grumps would say about the way that you are feeling and spending your time lately?” I asked. Abe thought for a while. “They actually talk about things like anxiety and stuf sometimes,” he said, followed by, “I’m gonna fnd one of the videos where they talk about their problems, and I will show it to you next time I see you.” As promised, at the next session Abe played a video on his phone showing the Game Grumps talking about their own experiences with anxiety and how they sometimes need to rely on their friends and family for support when things get bad enough. “What does that mean to you?” I asked. “It’s ok to need help?” he answered in question form. “If you could make a YouTube video to help other people who are trying to transition to being an adult, what would that look like?” I asked, followed by, “What game would you play?” Abe’s interest was piqued. He had been considering dabbling in streaming some of his gaming sessions for over a year and liked the idea of talking through the details. “I  would defnitely play League of Legends,” he said, “because I am good at it, and there are several stages of development for players that could be compared with stages of development in life.” “I like the way you are thinking!” I responded, followed by, “Can we compare your growth with that of one of the champions (the name for characters in the game) in League of Legends?” As expected, Abe was able to do this, using his favorite character, Yasou (“The Unforgiven”), as inspiration. His treatment plan was easy to write from there, with new strengths and changing champions taking center stage.

Let’s Plays in Psychotherapy: One Approach LPs can leverage the benefts of both video games (e.g., engaging, promoting therapeutic relationships, diagnostic value) and YouTube videos (e.g., normalize mental illness, reduce isolation, enhance mental health provider’s understanding of the problem) in therapy. LPs in counseling can be used for normalizing, challenging stigma, psychoeducation, and empowerment. They can also be used as a tool to provide insight into clients’ understandings of their realities. LPs

YouTube and Let’s Plays in Psychotherapy

97

carry meaning to clients, and capitalizing on this meaning can be an efective approach in therapy. One possible approach to using LPs in psychotherapy is described next. The current approach would be used, usually early in therapy, to facilitate the process of making and discussing a possible diagnosis. It can also be used to help communicate with a client regarding experiences with normal anxiety, family, and school-related stress. This approach works because it diverts the attention away from a client’s problem (externalization) and allows the mental health provider to learn about client values and experiences through their connection to the LP creator. The approach is consistent with narrative therapy and provides opportunities for values clarifcation and other approaches to psychotherapy as client issues are acknowledged and processed. For example, techniques such as the gestalt “empty chair” can be used to process client experiences where advice or guidance would be helpful (e.g., “What would the Game Grumps say about how to handle that?”). In terms of video selection, those in which the creator is talking about his or her own experiences should be used when possible to avoid inaccurate statements and promote de-stigmatization. If the material that addresses mental health occurs outside of the context of an LP, the source of therapeutic benefit may be harder to isolate. An example of this is commentary that occurs while gameplay is paused. Step One Assess your client’s interest in video games and/or LPs during the strengths/interests inventory. Ask your client what her/his favorite YouTube channels are and if she/he watches LPs. Templates for the strengths assessment are included in the appendix of this book (Appendix 1). Step Two Option A. Collaboratively select an LP (like one from Table 8.1) that best matches the client’s interests and reported symptoms. Asking clients if any of the YouTubers who they follow have talked about experiences with things like anxiety or other issues pertinent to the reason for referral can also be helpful at this time. Option B. For skilled video makers, consider asking them to make their own LP in which they describe their experience while playing a video game that fts.

98

Table 8.1 Selected LPs Link and relevant time stamps

Age range

Themes (in order of prevalence)

Brief description and considerations

REAL TALK: Why Max Stopped Competing (UMVC3 Gameplay) by Maximillian Dood Wind Waker HD: Fresh Air—PART 19 — Game Grumps The Legend of Zelda: Twilight Princess HD Versus—Episode 2 Twilight Princess HD: The podcast. (#27) by 2 People Playing Games

https://youtu.be/wrkhrbKfZeU (5:54–14:54)

13–16; 17+

Panic attacks, workrelated stressors, anxiety

https://youtu.be/MfTNZLssib4 (0:45–10:00) (10:25)

17+ (for explicit language) 17+ (for explicit language) 17+ (for explicit language)

Depression, OCD

Discusses personal experiences and symptoms of panic disorder Learning about and understanding a diagnosis YouTuber comes out to audience

Twilight Princess HD: Sweating. (#36) by 2 People Playing Games That Dragon, Cancer by Markiplier

https://youtu.be/jjN1hOLaGvA (4:54–10:00)

17+(for explicit language) 13–16, 17+

Anxiety

https://youtu.be/YUiqfRt4UKM (17:40–20:50) https://youtu.be/43jZLmvIEec (0:00–4:20) (4:57–8:18)

https://youtu. be/5sWTD6vmH_U (0:0–1:55) (13:40–14:23) (28:45–58:00) (1:18:38– 1:22:40) (1:47:30–1:55:00)

Identity, sexuality Anxiety, depression, normalizing therapy

Grief, depression

Discusses personal experiences with anxiety/ depression Focuses on biological aspects of anxiety Deals with terminal illness of loved one

YouTube and Let’s Plays in Psychotherapy

Title + YouTuber

Super Mario Galaxy: Adorably Goofy—PART 69—Game Grumps

17+(for explicit language)

Work-related stressors, depression

General emotional distress

13–16, 17+

Depression, workstressors, self-care

Discusses balancing work and self-care

https://youtu.be/v6eWvJC_nII (0:00–11:40)

17+ (for explicit language) 17+(for explicit language) 13 and older

Depression, workstressors, self-care

Discusses balancing work and self-care

Depression, normalizing therapy

Graphic material, discusses LPs, mental health Information about anxiety and CBT is provided while playing Minecraft

https://youtu.be/RWvItT0zVAY (23:50–25:50) https://youtu. be/9WchAHTZF2c

Anxiety and CBT

YouTube and Let’s Plays in Psychotherapy

Super Mario Odyssey: Real Talk—PART 20—Game Grumps Super Mario Odyssey: Life and Work—PART 21— Game Grumps THE HORRIBLE TRUTH REVEALED| The Park #2 by Jacksepticeye Anxiety & CBT—Xisuma Says

https://youtu.be/ Z8WX3FaoGXM (1:27–2:50) (9:10–9:45) (11:10–13:55) https://youtu.be/AsF2xtOp6Uc (0:00–10:10)

99

100

YouTube and Let’s Plays in Psychotherapy

Step Three Option A. Ask the client to watch the selected LP between appointments (or fnd one by a YouTuber they follow that relates to their own experience). The client should record reactions, feelings, and questions in regard to LPs and be prepared to discuss these reactions during the next session. Option B. Consider watching the prescribed or client-discovered LP together, especially if there are concerns related to the client’s ability to use technology properly. Step Four Discuss and process your client’s refections from step three. Consider providing a handout or questions to answer, such as those listed next or included in the appendix of this book (Appendix 13). This approach to therapy has also been used with movies (e.g., Garrison, 2007). • • • • • • •

In what ways do you relate to what the YouTuber was saying when he was talking about (anxiety, depression, etc.)? What did you learn from listening to the YouTuber’s experience? In what ways did you relate to the YouTuber? If you could give the YouTuber advice, what would you say? Is there anything you think this YouTuber could advise you on? If you had to choose a video game to pair with your experience, what would it be? How come? What about what the YouTuber said did you not agree with? How come?

Step Five Use your client’s reactions and responses as information to guide next steps related to diagnosis and, ultimately, externalization of that diagnosis. Ideally, the client will be able, with the mental health provider’s help, to see the problem as the problem through this process (Madsen, 2007). Reconnecting with the client’s favorite YouTubers to address issues as they come up later in psychotherapy can also be a great way to create a nonjudgmental environment (e.g., “What do you think the YouTuber would say about your current situation? Is there anything you think they could help me understand?”).

Conclusions, Limitations, and Opportunities for Future Research Since LPs are a reasonably new idea, research on their efectiveness in therapy is virtually nonexistent. However, research

YouTube and Let’s Plays in Psychotherapy

101

supporting the efectiveness of YouTube in mental health is growing. With the world of technology continually evolving, mental health providers should embrace and adapt as much as possible while maintaining a base in empirically supported methods. By using video games, YouTube, and LPs, mental health providers can meet clients where they are at and form more efective therapeutic relationships. LPs in therapy can make it more comfortable for young people to relate to the therapist while providing a framework for understanding client issues. The diversity and varieties of LPs can be used for discussion between mental health provider and client, which improves engagement in the therapeutic process. Through LPs, mental health providers can gain insight into complex issues in clients’ lives. They can foster the learning of therapeutic concepts and allow clients to gain awareness of symptoms, causes, and coping skills related to mental health. LPs can be used as a form of psychoeducation and can promote mental health awareness with clients. Allowing clients to create an LP that communicates their own experience can help them to feel less excluded, feel hopeful and supported, and share personal experiences and coping skills. As with video games in therapy, using LPs may be perceived as controversial by many parents and professionals. Parents may not understand or see the value in using these techniques therapeutically. Additionally, it can be challenging to select LPs that are appropriate for therapy. When using LPs, clinicians would need to be judicious in selecting clients who have a genuine interest in the medium and capacity for externalized ways of thinking. Mental health providers would also want to ensure the LPs used in the session are of interest to and developmentally appropriate for the young person for whom the LP is “prescribed.” Many games that discuss mental health have disturbing content that can be triggering. The appropriateness of this type of content can vary based on the age of the client and other factors, such as the use of profanity. Future research might include efcacy studies for the use of LPs in psychotherapy, as well as a more extensive search for additional videos and standards for their inclusion in therapy. Studies focusing on the impact of using LPs for psychoeducation, diagnostic understanding, and treatment adherence would all go a long way toward convincing mental health professionals and their employers to provide training and resources (e.g., technology). Additionally, research on the actual prevalence of LP views by young people with specifc diagnoses may inform who to use this approach with.

102

YouTube and Let’s Plays in Psychotherapy

Common Questions and Answers Question How was the approach described in this chapter developed?

Answer Exploration of using Let’s Plays in therapy began upon discovering their value to clients regardless of whether the LP included mental illness– related content or not. This was identifed during the strengths assessment process, when clients were asked about their interests and where they fnd meaning. We began to question whether personal accounts of mental health expressed by LP creators can help destigmatize mental illness. We also wondered if client comfort with LPs as a medium may help make the process of discussing mental illness less intimidating. We learned that LPs can be useful in a therapeutic setting when they are utilized for externalization during the discussion of diagnoses and other stressors. Not surprisingly, the literature supported this concept. Subsequently, we developed and refned the approach with nine clients. Anecdotal evidence from this process suggests that it was a reasonable place to start. This approach includes strategies from narrative therapy (e.g., focus on strengths and personal narrative; reauthoring), values clarifcation (e.g., unfnished sentences), cognitive behavior therapy (e.g., externalization), and family systems therapy (e.g., strategic and structural). The LPs selected for inclusion in Table  8.1 were chosen from a list of 30 videos that were discovered by three motivated young volunteers working with the practice site (i.e., The MindFit Experts). Their process included a thorough internet search, as well as personal letters sent to several of the YouTubers that they and other clients of the practice follow. After selection, the videos were screened for accuracy and appropriateness by graduate students in mental health counseling and given scores based on their potential value in therapy. The approach itself was refned and informed by dozens of young clients, most meeting criteria for autism spectrum disorder, anxiety, and/or other mental health issues common in children and adolescents. Originally, we were only looking for LPs that included minimal dark or disturbing content and commentary related to mental illness that: 1) was from personal experience, 2) occurred during active gameplay, and 3) did not have a direct relationship to the game being played. We ultimately decided to include a wider range of content, including workrelated stress and non-pathological forms of sadness and anxiety. Once we had identifed 30 LPs that met our new criteria, we began the process

YouTube and Let’s Plays in Psychotherapy

103

of screening each video for accuracy, potential risk, and inappropriate content. The remaining videos were categorized based on theme and age group.

Question Shouldn’t I be worried about my clients posting material on the internet that could come back to haunt them?

Answer Monitoring internet safety is an important part of using YouTube and LPs in psychotherapy. Clients who have a history of poor judgment while using the internet may not be good candidates for this approach. In most cases, it is not advisable that clients post their videos that were created in psychotherapy.

Question How do I fnd LPs with mental health themes?

Answer When in doubt, ask your clients to fnd videos by their favorite YouTubers that remind them of themselves and their reasons for seeking psychotherapy. Key words such as “anxiety let’s play” or “LP video about bullying” will bring back several options that should be viewed in advance for accuracy and appropriateness. Searching the examples provided in Table  8.1 of this chapter and looking at related videos can also be an efective way to mine for useful content.

Question Should I  be worried that my client’s primary relationships are on the internet?

Answer As discussed elsewhere in this book, everyone is diferent in terms of their requirement for friendships. That said, some people really do not know what they are missing until it is made available to them. Internet relationships and connections are not always ideal ways to learn and practice one’s template for relationships, but they do provide one way that is often more realistic, safe, and accessible for people with mental

104

YouTube and Let’s Plays in Psychotherapy

illness. If nothing else, the COVID-19 pandemic has certainly taught us how valuable online relationships can be.

Therapist Missions • •

Start asking about what Let’s Plays your clients watch! Consider developing your own list of Let’s Plays to use with your population of interest.

References Burwell, C. (2017). Game changers: Making new meanings and new media with video games. English Journal, 106(6), 41–47. Burwell, C.,  & Miller, T. (2016). Lets play: Exploring literacy practices in an emerging video game paratext. E-Learning and Digital Media, 13(3–4), 109–125. Garrison, D. (2007). Use of movies to facilitate family engagement in psychiatric hospitalization. Journal of the American Academy of Child & Adolescent Psychiatry, 46(9), 1218–1221. Glas, R. (2015). Vicarious play: Engaging the viewer in let’s play videos. Empedocles: European Journal for the Philosophy of Communication, 5(1), 81–86. Madsen, W. (2007). Collaborative therapy with multi-stressed families. Guilford Press. Menotti, G. (2014, March  1). Videorec as gameplay: Recording playthroughs and video game engagement. G|A|M|E The Italian Journal of Game Studies. ISSN 2280-7705. Naslund, J., Aschbrenner, K., Marsch, L., & Bartels, S. (2016). The future of mental health care: Peer-to-peer support and social media. Epidemiology and Psychiatric Sciences, 25(2), 113–122. Naslund, J., Grande, S., Aschbrenner, K., & Elwyn, G. (2014). Naturally occurring peer support through social media: The experiences of individuals with severe mental illness using YouTube. PLoS One, 9, E110171–E116203. O’Keefe, G., Clarke-Pearson, K.,  & Council on Communications and Media. (2011). The impact of social media on children, adolescents, and families. Pediatrics, 127(4), 800–804. Oliphant, T. (2013, December 1). User engagement with mental health videos on YouTube. Journal of the Canadian Health Libraries Association, 34(3). Woo, B., Lam, N., & Kung, E. (2018). Use of YouTube to reduce mental health stigma. International Journal of Social Psychiatry, 64(4), 406–407.

Chapter 9

Serious Games and Games for Health

What Are Serious Games and Games for Health? A  serious game  is designed for a primary purpose other than pure entertainment. The “serious” adjective refers to video games used by industries such as defense, education, scientifc exploration, health care, emergency management, city planning, engineering, and politics. The idea shares aspects with simulation but explicitly emphasizes the added value of fun and competition. “Gamifying” important or nonpreferred activities is quickly becoming a favorite way to promote adherence and productivity for business (Küpper et  al., 2021), education (ParryCruwys & MacDonald, 2021), and health care (Theng et al., 2015). Games for Health is a category of serious games focused on health care. Each year, there is a Games for Health and Games for Health Europe conference held near Boston and the Netherlands, respectively. MindGamers, the game described previously in this book that helped motivate many other ideas for using video games in psychotherapy, was presented at Games for Health Europe in 2014. Specifcally, the process used to create MindGamers was the focus of this presentation. The current chapter will share this information along with lessons learned while developing games for health since MindGamers.

Examples of Serious Games for Mental Health There are several websites now that proclaim to provide a wide array of minigames and activities intended to promote a healthy mind. Websites such as Luminosity.com advertise that they ofer scientifcally validated tasks and turn them into fun games, actionable feedback, and rich insights into one’s cognition. While these sites can be helpful for some people and should not be discouraged, they are not designed or studied to meet the needs of people with mental illness. Often, the activities that tend to have the most impact are those that use gamifcation to promote DOI: 10.4324/9781003222132-9

106

Serious Games and Games for Health

adherence to afrmations and gratitude routines (Cascio et  al., 2016; Cohen  & Sherman, 2014). Mental health providers can accomplish similar outcomes by collaboratively gamifying these types of therapeutic assignments. For example, a client who is given the task of vocalizing three things that she is grateful for each day might decide with her psychotherapist that she will give herself one point for each gratitude, and an extra point for thinking of something about herself that she is grateful for. The client and her mental health provider could agree that she should set a goal of earning 28 points weekly for which she will earn a reward of some sort when accomplished. A sampling of the games that have been specifcally designed to help with anxiety, depression, and other mental health problems is presented next. These games are suggested as an adjunct to therapy with the support of a qualifed mental health provider. None of these games is approved by the FDA, as FDA approval for video games remains an area of uncertainty and has only been achieved by one game as of the publication of this book. FDA approval for games for health is discussed in more detail in the Common Questions and Answers section of this chapter. •

•

•

•

•

•

Celeste is a story-based video game centered around climbing a mountain. It was designed to help players develop skills for coping with depression and anxiety, as the main character battles her own inner demons. Depression Quest  is an interactive fction game. The player is someone living with depression who must manage her/his mental illness, relationship, job, and possible treatment while navigating a series of everyday life events. This game aims to show other suferers of depression that they are not alone in their feelings and to illustrate to people who may not understand the illness the depths of what it can do to people. Gris is a game that shows how the main character, a young girl, slowly learns to cope with grief and loss through puzzles and skill-based challenges. Gris is a serene and elegant game that includes no violence, making it a safer option for many young people. Hellblade: Senua’s Sacrifce is a game intended to teach coping skills for psychosis through the eyes of a Celtic warrior named Senua, who is attempting to save the soul of her lover. It includes vibrant and captivating graphics that are intended to capture the attention of its players in a way that other mediums do not (e.g., traditional talk therapy). Night in the Woods is a game that helps players develop coping skills for depression and anxiety. Players play the character Mae, a woman who dropped out of college and returned to her hometown to fnd everything looking darker and scarier. In Sea of Solitude, the main character, Kay, becomes a monster as her loneliness, anger, and feelings of hopelessness and worthlessness

Serious Games and Games for Health

107

take over her life. The player helps Kay develop insights and skills for recovering from these feelings. In this way, Sea of Solitude is an excellent option for mental health providers who utilize a narrative approach to psychotherapy.

MindGamers and Interprofessional Design MindGamers (MG) is a biofeedback-controlled video game. It was designed to therapeutically engage young people with anxiety-related issues by teaching psychophysiological self-regulation skills. The process was inspired by an increasing need to better engage young people with anxiety and other issues with psychophysiological self-regulation in the psychotherapy process. The original concept was brought to prototype form by Jacobs et al. (2012). Rice (2016) later studied player’s physiological responses to the animated “triggers” in MG, demonstrating that animated, computerbased images can infuence a player’s heart-rate variability. MG, like many ideas in this book, used narrative and cognitive-behavioral concepts to help middle-school-aged children learn skills for confronting anxiety-provoking stimuli. The game was created to be played during psychotherapy sessions and started with a built-in strengths assessment that was represented by a metaphorical “utility belt” like that worn by Batman. After identifying their strengths and choosing images to fll their utility belts (e.g., sword, microphone, glasses, dog), players were instructed by their mental health provider to create an avatar representing themselves. Players then created a “goal-directed imp” and a “problem-based imp” to represent their ideal self and the problem, respectively. As stated multiple times in this book, the process of creating characters to represent the problem can be an efective way to both externalize the problem and to learn about the person’s relationship with the problem. The goal-based imp was essentially a shrunken version of the player’s avatar that could be dressed in superhero skins and wore the utility belt full of the individual’s strengths and skills. In the game, the imps follow and infuence the player’s avatar and gameplay. For example, the problem-based imp may push the player’s avatar of track, impeding his or her progress in the game. On the other hand, as the player calms, the goal-directed imp pulls the player’s avatar in the direction of the mission (e.g., get to class on time) unhindered. For the fnal step in game set-up for MG, the mental health provider and the player identify conditions that trigger the player’s anxiety. These are represented as icons that depict social and inanimate stressors that the player encounters in real life. They can be pulled into the game environment and strategically placed at several locations within the middle school environment for the player to encounter during gameplay. The player also sets the avatar to be attracted to (e.g., in order to clean up, straighten) or to avoid these triggers during gameplay. It should be

108

Serious Games and Games for Health

noted that while the description of this process seems drawn out and laborious, in practice it involves a dynamic and engaging give and take between mental health provider and player that contributes greatly to the therapeutic process. Gameplay requires two sets of inputs. The frst is via standard PC game controllers like a keyboard and mouse. The second input device is a NeXus-10 wireless transducer that reads respiratory rate (RSP), peripheral skin temperature (TMP), skin conductance level (SCL), and blood volume pulse (BVP) as proxies for autonomic nervous system balance (ANSB: stressed versus calm), which are then dynamically summed and represented as a “Stressmeter” on the game’s display. This portion of the game is derived from the work of Sugarman and Wester (2007), Sugarman (2000), and Reaney et al. (1998) on psychophysiological self-regulation. This covers the core mechanic of MG, the interplay between game environment, avatar control, and player’s internal state. Once a player successfully reaches a goal within the game (for example, getting to class on time) gameplay shifts to a secondary mechanic of minigames that represent “daydreaming” in class. While in the real world of classroom behavior this is seen as detrimental, in the therapeutic world daydreams ofer another opportunity to rehearse and review strategies. So, the minigames are a reward and add fun at several levels. First, they ofer a less therapeutically directed opportunity for play. Second, if the player scores well at them, the minigames will award bufs, like enhanced avatar capabilities, in the core game. The frst functional prototype, and the results of the initial patient usability studies have been presented at the American Society of Clinical Hypnosis, Charlotte, March 2012; the International Meeting for Autism Research, Toronto, May 2012; and Games for Health, Boston, June 2012. The second phase of production, to develop a wider and deeper prototype, began in June 2012 and was presented on at Games for Health Europe in 2014. In time, it was determined that the game would be too expensive to build and commercialize, so eforts were made to extrapolate what was learned from MG to create more accessible games and apps. One of them, Repetition Rebellion, is described later in this chapter. For those innovative entrepreneurs who have an idea for a serious game to help the population they specialize with, the next section ofers an outline for design and opportunity to learn from MG. Designing Mental Health Games; Learning from MindGamers Games for health, like MG, are often built by a team that includes a project manager, a development team, and a clinical team. When the Rochester Institute of Technology (RIT) provided the initial seed funding for the development of MG in 2011, the frst of two six-month waves

Serious Games and Games for Health

109

of development began with the recruitment of three student developers who would work as full-time co-ops for that period. The frst three months were dedicated almost exclusively to research, conceptual design, and physical prototyping. Much of the frst six weeks was devoted to ensuring that the clinical team and the student development team achieved a common understanding of each other’s roles and expertise, as well as a common understanding of the therapeutic and technical needs of the project. Crossing the Language Barriers One of the most difcult and most important aspects of building a video game for mental health is fnding a way for the clinical team and development team to understand each other’s language and perspectives. For MG, the clinicians and development team met early in the design process to expose each other to biofeedback and psychotherapy on the clinical side, and coding and design on the development side. These meetings took precedence during the frst two months of game development and promoted a richer product that accurately represented the clinical concepts used. During the meetings, the clinicians provided the development team with readings (e.g., selected chapters from Schwartz & Andrasik, 2003; Andreassi, 2006; Cacioppo et al., 2007; Madsen, 2007) and led discussions on the material to ground the team in the concepts and language required to navigate the theory and practice. Likewise, the clinical team needed to develop their understanding of some aspects of video games with which they were less familiar. As character customization is key to MG, the team all acquired trial licenses for City of Heroes from NCSoft, Inc. (NCsoft, 2012) because it is recognized as having a ground-breaking and deeply detailed system for this in modern computer games. The teams also went through character customization, training levels, and some initial missions to get a feel for those aspects of games. Finally, they were introduced to Rockett’s New School (Purple Moon, 1997), Journey to the Wild Divine, (Wild Divine, 2002) and game aspects of the HeartMath EmWave (Heart Math, 1991) and MindMedia Biotrace+ (Mind Media, 2004) systems. Defining Design Once the team members understood each other’s concepts, vocabulary, and roles, they began to move forward by revisiting the clinical team’s original High Concept Document for MG. The goal at this point in the development process was to create a board game prototype that captured the desired gameplay. Prototyping was also done via role playing and enactment of what would happen in the game. Role playing as a

110

Serious Games and Games for Health

prototyping method became key to the team’s gaining a clear understanding of gameplay and goals. This was clear in the following example. The team was discussing how a player’s avatar and imps might react to a trigger in the game. There was a deadlock in the discussion. The clinical and development teams were unable to communicate a potential scenario from the game prototype. So, they acted it out together. The example used was a dirty trash can in the hallway of the school and how a player’s avatar and imps might react to it. By identifying a chair as the dirty trash can and acting out the scenario in the meeting, it became clear that the sticking point had been the development team’s difculty in understanding that there would be diferent players’ reactions to the trash can and subsequent behavior. What the clinical team was trying to communicate was that some players might be compulsively attracted to the can out of a need to clean it up, while others might go all the way around the school to avoid it. By acting the gameplay out, the diference in players’ reactions became clear in a way they had not before. This led to the creation of another layer of refnement in the game set-up between player and mental health provider before the game begins. As the game design process progressed, several other issues emerged that were not made evident by the board game prototype. As a result, the team acted out several more scenarios in their eforts to refne gameplay and ensure clinical relevance. For example, the interaction between the imps was refned to be one of infuencing the player’s avatar and engaging each other in non-combative ways rather than directly battling with each other. This was done to keep the game’s focus primarily on the player’s internal state. Furthermore, the role of the devices, weapons, and armor on the “utility belt” were refned to be representational rather than actual aids to combat. The daydreaming minigames, an addition to the game above and beyond the original ideas from the clinician, was devised by the game development students and came from their greater understanding of “more fun” and additional rewards in the game to increase player engagement and enthusiasm for MG. Placing the game development faculty member (project director) in a “Guide on the Side” role allowed both teams, clinical and development, to work more organically as two halves of a whole, each treating the other as experienced experts in their felds. The goal of creating a game for health that utilizes evidenced-based game design required this diversion from a lead designer as in more traditional approaches to maximize communication and limit barriers caused by diferences in expertise and professional language. Setting Process and Scope Scoping and tiering development of games is a crucial piece of the development process. The teams quickly identifed fve/six major areas of the

Serious Games and Games for Health

111

game’s development: 1) the connectivity and communication of sensors to the Unity game engine that would be the development environment, 2) the patient/mental health provider preferences (selecting conditions and triggers), 3) the avatar customization process, 4) the core gameplay mechanic of interplay between player internal state, 5) the imps and the game level environment, and 6) the daydreaming minigames. The team, after in-depth discussions, ranked those based on importance: 1. 2. 3. 4. 5.

Connectivity Core mechanic Avatar creation Player preferences set-up Minigames

While it was clear that the frst two were critical to the concept of the game overall, and the most challenging technical aspects of development, it was important to the clinical team to also begin prototyping the avatar selection. It was key for them to evaluate the overall approach with their target population to ensure the game concept was on the right track. To accomplish those goals, the decision was made to do some rapid prototyping of the avatar creation portion of MG with Adobe Flash, rather than trying to build that in the Unity engine as well. This decision proved fortuitous because it allowed the avatar creation prototype to stand alone for use with the clinical team’s clients who provided valuable feedback to the development team. Conclusions and Future Study Putting signifcant upfront time and efort into ensuring that all members of all teams develop an understanding of each other’s roles and language is key to game development outside of entertainment games. Ensuring that each group learns from, and plays with, the other reduces tensions and misunderstanding that can occur in a more traditional “Contracted SME” environment. A fatter, less hierarchical team structure (while harder to achieve when one team consists of professors and the other consists of undergraduate students) leads to additional, and unexpected, avenues for innovations in the game. For the clinical team, game development concepts learned in this interactive process informed therapeutic processes.

The clinicians were able to play virtual, imaginary games with the young people in their care with the ideas and dynamics to be employed eventually in the prototype. So, even before there was a completed game, the game changed therapy (and therapy changed the game).

112

Serious Games and Games for Health

University-based games for health development teams must remain especially cognizant of issues related to intellectual property, contemporary research, and the protection of human subjects. This is because these projects tend to rely on grant funding and institutional support for success and involve issues related to client confdentiality and related rights. Evidenced-based game design requires that all team members keep client preferences and related research at the forefront of their eforts. It is not enough to make a game that you think will help people. A successful game for health must start and end with those you intend to help and the research exploring efective treatments for that population.

Repetition Rebellion and Other Apps Designed to Help in Psychotherapy Repetition Rebellion (RR) is an app that emerged from MG that is intended to help make the process of tracking progress with psychotherapy homework between sessions more engaging, thereby increasing adherence. Using RR, clients can: 1) be reminded of their strengths and skills, 2) externalize problems, 3) set “missions” between therapy sessions (e.g., practice abdominal breathing), 4) journal, and 5) use tools like a breathing pacer to assist their eforts. This is accomplished using the following buttons/functions: Main Menu The frst screen that appears is when the app boots up. From here, the player can access other areas of the app. It also functions as an “at a glance” dashboard of the system, letting the client know what they are working on. Utility Belt Screen This is the integrated strengths assessment for RR. The utility belt is the portion of the app where the client and his/her mental health provider select visual representations of the therapeutic “tools” that the client is practicing or anticipates using when confronted with a challenge. The client would select from an inventory of graphic images generated from research with 12–15-year-olds with anxiety. For example, the client might choose a sword to represent his/her “sharp wit.” Characterizer Screen The avatar(s) that user(s) will create with this program are not a visualization of the client but of the client’s externalized problem. This is where the process of “characterization” begins. The types of avatars were generated via extensive interviews with clients who requested that nonhuman and non-humanoid options be included.

Serious Games and Games for Health

113

Mission Creation Screen This is where the mental health provider and client determine the goals to be worked toward between sessions. A goal name and description are created, and the avatar and tool belt are assigned to it. When a mission is saved, a journal section is opened for it. Progress can be “scored” for each mission created. Journal Screen This is where clients record text or audio notes on their progress with missions.

114

Serious Games and Games for Health

A possible treatment protocol for RR is proposed next to provide guidance on how an app such as RR might be used in the therapeutic process. Similar apps and gamifed to-do lists are available for use now, and new-and-improved versions are being created as you read this book. You can also combine existing technology (e.g., character creators, to-do lists, breathing pacer apps) to achieve the same outcome. About Appointment One—Introduction 1. 2. 3. 4. 5.

Discuss the app and purpose with the client. Fill the utility belt with metaphors for the client’s self-identifed strengths and skills. Consider future strategies or strategies to be learned in therapy. Use the app to enter these strategies and choose metaphors (tools). Play with the characterizer and decide on an externalized problem to defne a character. Assign homework to create a character that represents the externalized problem.

About Appointment Two—Problem Externalization 1.

2. 3.

Have the client show the character that she/he made on the app. Question the client on the meaning of choices and use this as an opportunity to ask deconstructive questions that help explore the relationship between the person and the problem. Introduce the breathing pacer and provide psychoeducation on abdominal breathing (see Chapter 4). Collaboratively create a reminder in the app to practice abdominal breathing at an agreed-upon frequency.

About Appointment Three—Mission Development 1. 2.

3. 4.

Choose at least three places where the externalized problem shows up in the client’s life and ask the client to list and rank these based on difculty. Starting with the easiest, ask the client deconstructive questions to help determine initial mission(s) (including “What gives the problem its power?” “When is it the strongest?” “What infuences it?” “What supports it?”). Defne “missions” as using the app to exercise learned skills, either to cope with a challenging situation that has powered the problem or for skill building. Discuss goals and rewards for achievement (e.g., new options for character creation and/or utilities in the app).

Serious Games and Games for Health

115

About Appointment Four and Beyond—Review Implementation and Refine 1. 2. 3. 4. 5. 6.

Review the client’s progress with mission(s) from the previous appointment using the app on the clinician’s dashboard. Use reauthoring questions to reinforce the progress made and establish a new mission. Re-visit the utility belt and adjust based on the client’s preferences. Continue to provide digital or other reinforcements for successful mission(s). Problem solve if the mission was not completed. Consider additional characters or missions based on the client’s needs and progress in therapy.

There’s an App for That! Apps designed to help people stay on top of health-related tasks are as old as the smartphone. In particular, “vanity apps,” such as Zombies, Run! that turns your jog down the street into an episode of The Walking Dead, assist people with their exercise routines. Similarly, apps such as Headspace have made it easier for many people who may have otherwise felt overwhelmed or incompetent to engage in meditation and mindfulness practices. A  sampling of apps that have been used effectively to support psychotherapy with young people is provided next. Mental health providers are encouraged to frequently update their list of recommended apps, as new apps are often being developed and older apps often stop working when there is no longer a back end to keep it populated and updated for new operating systems. My Life Ofers over 400 mindfulness activities, such as meditation, breathing, yoga, guided journaling, and more. This app is useful in encouraging self-care and taking moments out of the day to focus on oneself. My Life is recommended for teenage clients with anxiety. BoosterBuddy Useful in encouraging moments for oneself and implementing self-care routines. An avatar buddy checks in on the user daily and provides suggested coping skills. Users can also track medications and appointments, and there is a section to save one’s favorite quotes. BoosterBuddy is recommended for children 9–13 years old.

116

Serious Games and Games for Health

Emotionary Helps young people identify the fve primary emotions and those in between. This app aims to help children diferentiate between feelings and build their emotional intelligence and vocabulary. Emotionary is recommended for children fve to nine years old. Manatee and Me Uses CBT and other evidence-based methods to encourage mental health care for kids. The whole family can be involved when using Manatee and Me. Parents (or mental health providers) can set goals for kids that can be redeemed for rewards, like going for ice cream or a trip to the zoo. There is a chatbot that your child can interact with to work on CBT exercises. This app is advertisement free and HIPAA compliant. Insight Timer-Meditation App A free meditation app with thousands of guided meditations. Users can customize their meditation experience by selecting the focus and duration of each session. This app explores topics of deep sleep, leadership, concentration, and many more. Join thousands of others in group discussions and community features.

Common Questions and Answers Question Are games designed to assist in psychotherapy for young people FDA approved?

Answer FDA approval for serious games is a developing thing, as there are several barriers to following current protocol (e.g., speed of technology advancements, uncertainty about how games and apps will be used in psychotherapy). As of the publication of this book, there is one video game that has been ofcially approved by the FDA for the treatment of ADHD in children. The game, EndeavorRx, was approved on June  15, 2021. It was based on multiple studies, but especially on research involving another game, NeuroRacer, that was clinically demonstrated to improve cognitive control in adults. Using NeuroRacer, Anguera et  al. (2013) show performance benefts that extended to untrained cognitive control abilities (i.e., enhanced sustained attention and working

Serious Games and Games for Health

117

memory) that lasted six months after playing the game. These fndings provided the frst evidence of how a custom-designed video game can be used to assess cognitive abilities across the life span, evaluate underlying neural mechanisms, and serve as a powerful tool for cognitive enhancement. The FDA Approval Notice stated: The EndeavorRx device ofers a non-drug option for improving symptoms associated with ADHD in children and is an important example of the growing feld of digital therapy and digital therapeutics,” said Jefrey Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health. “The FDA is committed to providing regulatory pathways that enable patients timely access to safe and efective innovative digital therapeutics. The FDA reported that they reviewed data from multiple studies in more than 600 children, including studies that evaluated, among other things, whether participants demonstrated improvements in attention function, as measured by the Test of Variables of Attention (TOVA), academic performance measures, and other assessment tools. There were no serious adverse events reported. The most common adverse events observed with EndeavorRx are: frustration, headache, dizziness, emotional reaction, and aggression. The FDA reviewed EndeavorRx through the De Novo premarket review pathway, a regulatory pathway for low- to moderate-risk devices of a new type. This action created a new regulatory classifcation, which means that subsequent devices of the same type with the same intended use may go through the FDA’s 510(k) premarket notifcation process, whereby devices can obtain marketing authorization by demonstrating substantial equivalence to a predicate device. Presumably, this will pave the way for more serious games to secure FDA approval in the future.

Question How are games for health funded?

Answer Currently, most serious games designed to treat mental illness are funded by grants (foundation and federal) or by academic departments of supported research. While efective to an extent (as with MG), these funding mechanisms often result in great ideas becoming academic projects (as with MG), slowing their development, and limiting their impact. Even apps such as RR can cost several hundred thousand dollars to bring an idea to a research-quality prototype, making their development

118

Serious Games and Games for Health

a high-risk proposition for most game development companies. Most video game and app development companies strategically focus on games for entertainment or “vanity” (e.g., weight loss, ftness), as these are the products that tend to make the most money and carry the least risk. For health-related games to become more mainstream and widely developed, larger game development companies will need to be convinced that their eforts will be rewarded. It is possible that these larger companies will begin to see more potential to develop games for health when FDA approval and insurance reimbursement for such games has been sorted out. Until then, games for health are likely to continue to originate in universities, limiting their short-term impact.

Therapist Missions • • •

Consider investing in a serious game designed specifcally for your population of choice. Start building a list of apps for use with your clients. Update this list every six months to account for new apps and apps that have been allowed to fade away. Do you have an idea for a new game for mental health? Go for it!

References Andreassi, J. (2006). Psychophysiology: Human behavior and physiological response. Taylor and Francis. Anguera, J., Boccanfuso, J., Rintoul, J., Al-Hashimi, O., Faraji, F., Janowich, J., Kong, E., Larraburo, Y., Rolle, C., Johnston, E., & Gazzaley, A. (2013). Video game training enhances cognitive control in older adults. Nature, 501(7465), 97–101. Cacioppo, J., Tassinary, L., & Berntson, G. (Eds.). (2007). Handbook of psychophysiology (3rd ed.). Cambridge University Press. Cascio, C., O’Donnell, M., Tinney, F., Lieberman, M., Taylor, S., Strecher, V., & Falk, E. (2016). Self-afrmation activates brain systems associated with selfrelated processing and reward and is reinforced by future orientation. Social Cognitive and Afective Neuroscience, 11(4), 621–629. Cohen, G.,  & Sherman, D. (2014). The psychology of change: Self-afrmation and social psychological intervention.  Annual Review of Psychology, 65,  333–371. Jacobs, S., Rice, R.,  & Sugarman, L. (2012, October  18–20). Creating mindGamersTM: Building communication, design and development process with clinicians, game faculty and students. In Brian Winn (Ed.), Proceedings of the meaningful play. n.p., Web.* Küpper, D., Klein, K., & Völckner, F. (2021). Gamifying employer branding: An integrating framework and research propositions for a new HRM approach in the digitized economy. Human Resource Management Review, 31(1), Article 100686.

Serious Games and Games for Health

119

Madsen, W. (2007). Collaborative therapy with multi-stressed families. Guilford Press. Parry-Cruwys, D., & MacDonald, J. (2021). Using gamifcation to promote accurate data entry of practicum experience hours in graduate students. Behavior Analysis in Practice, 14(1), 1–10. Reaney, J., Sugarman, L., & Olness, K. (1998). Taking biofeedback to where kids are. Biofeedback, 26, 30–32. Rice, R. (2016, January 30). Physiological responses to animated triggers for young people with autism spectrum disorder. American Association of Behavioral and Social Sciences Annual Conference. Schwartz, M., & Andrasik, F. (Eds.). (2003). Biofeedback: A practitioner’s guide (3rd ed.). Guilford Press. Sugarman, L. (2000). Hypnosis and biofeedback. In R. A. Hoekelman, et  al. (Eds.), Primary pediatric care (4th ed.). Mosby-Year Book. Sugarman, L.,  & Wester, W. (2007). Hypnosis with children and adolescents: A contextual framework. In W. C. Wester II & L. I. Sugarman (Eds.), Therapeutic hypnosis with children and adolescents (pp. 3–24). Crown House Publishing Limited. Theng, Y., Lee, J., Patinadan, P., & Foo, S. (2015). The use of video games, gamifcation, and virtual environments in the self-management of diabetes: A systematic review of evidence. Games for Health, 4(5), 352–361.

Chapter 10

Virtual Reality in Psychotherapy

Defining XR, VR, and AR Extended Reality Extended reality refers to a category of technology that provides users with an enhanced experience while using it. Virtual reality (VR) and augmented reality (AR) both fall in the category of extended reality, as does mixed reality (MR), which falls somewhere between VR and AR and merges the real and virtual worlds. One well-known MR game is Pokémon Go, which overlays the real-world environment with the Pokémon world. The current chapter will focus primarily on VR. Virtual Reality VR completely replaces a user’s view, immersing them within a computergenerated virtual environment. It is used primarily for entertainment purposes (e.g., gaming), but it is starting to infltrate the social domain as well. VR is also a common tool in training for professions such as health care, as it provides low-risk opportunities for surgeons and nurses in training to practice delicate surgery techniques. Augmented Reality AR enhances our view of the real world by overlaying what we see with computer-generated content. There are several useful applications for AR, which can be efectively achieved on a modern smartphone. For example, mountain climbers can easily identify the peaks they see from a particular summit by holding their phone up to the landscape. AR is also widely used in education, where new applications are being identifed daily that allow students to do things such as overlay virtual images or concepts onto their actual workspace. DOI: 10.4324/9781003222132-10

Virtual Reality in Psychotherapy

121

Applications and Evidence for VR in Psychotherapy VR is an efective tool in psychotherapy because it ofers the client full immersion into an environment which can be difcult to achieve in traditional treatment (Grochowska et  al., 2019). VR ofers a variety of interventions that can be tailored to individual preferences. Since VR mimics “real life,” it typically creates an experience of presence. Clients do not need to solely rely on their imagination when using VR to confront triggers to anxiety and practice new coping techniques. This is possible because the VR environment is controlled and provides space for direct client–therapist and therapist–client feedback. The client is an active participant in the therapeutic process when using VR. Research on the use of VR in psychotherapy is among the richest we have for the use of interactive media to treat mental illness. Although most eforts to this point have focused on using VR in psychotherapy with adults, new research is being published that looks more specifcally at the benefts for young people. For example, Farrell et al. (2021) found that VR was helpful at treating dog phobias in children. Likewise, Bomba et al. (2021) found that VR was a useful tool in conducting psychoanalysis with children and adolescents—a phenomenon that emerged during the COVID-19 pandemic. Some of the frst eforts to use VR in psychotherapy involved treating veterans with post-traumatic stress (e.g., Rothbaum, Hodges et al., 1999; Rothbaum, Ruef et al., 2003). Since then, there have been attempts to use VR with phobias, social anxiety, panic, OCD, schizophrenia, substance use, and eating disorders. Diemer and Mühlberger (2015) explored the major applications of VR in psychotherapy for most of these disorders; they break each section down into simple terms for understanding. The authors address the current literature on efcacy and provide future implications for psychotherapy and clinical research. Diemer and Mühlberger (2015) suggest that cognitive preparation, including psychoeducation, must be conducted before utilizing VR for therapeutic purposes. Riva (2005) did a review of the research available at that time, starting with the 1980s. Based on this review, Riva (2005) concludes that VR is efective because it is adaptive in mimicking perception of reality and has room for creativity. The researchers suggest that behavioral therapists can use VR to assist in activating the fear structure for a phobic client through controlled exposure and that cognitive therapists can utilize VR to assess situational memories or to disrupt habitual patterns of selective attention. Riva (2005) goes on to suggest that experiential therapists may fnd it useful to isolate clients from the external world to help them practice selective action using VR. Psychodynamic therapists

122

Virtual Reality in Psychotherapy

may use it as a symbolic system to evoke and release afect. Some of the specifc advantages of VR that were reported in this review were: 1) VR can be administered in traditional therapeutic settings, 2) VR is more controlled than other options, and 3) VR is cost-efective. Despite the many advantages and benefts, Riva (2005) was clear that the research on VR supports its use as an adjunct, not replacement for, traditional psychotherapy, as clinical skill remains the key factor in the successful use of VR. More recently, Grochowska et al. (2019) examined the use, efcacy, and value of VR as a tool in the treatment of mental health disorders, including anxiety, schizophrenia, and eating disorders. According to Grochowska et al. (2019), the research on VR in treating anxiety disorders  highlights that there is no signifcant diference in therapeutic progression between virtual reality exposure therapy (VRET) and cognitive behavioral therapy with systematic desensitization (CBT-SD). Factors favoring VRET include very low post-treatment deterioration when compared to CBT-SD, leading the authors to suggest that VRET should be considered more benefcial long term than psychotherapy without VR. In terms of VR applications for schizophrenia, Grochowska et  al. (2019) collected  research on the application of VR in enriching CBT interventions. They found that VR can be used to assess the severity of positive symptoms in schizophrenia because persecutory ideation in the VR environment will difer with schizophrenia and schizophreniform disorders. Grochowska et al. (2019) reported that clients experiencing delusions were more likely to report persecutory ideation in a VR session. VR was also found helpful for teaching social skills and vocational rehabilitation for people with schizophrenia, as well as to create virtual scenarios that enable people to interact with their auditory hallucinations. Based on the research they reviewed, Grochowska et  al. (2019) concluded that VR is efective in creating an environment where schizophrenic clients can challenge their delusional thoughts more efectively than with traditional CBT interventions. Research on using VR in the treatment of eating disorders suggests that the VR environment can be helpful in treating body image disturbance (e.g., Irvine et al., 2020). Using VR, clients with eating disorders can manipulate a virtual human fgure to represent their perception of their own body, allowing them to begin to understand that body perception is a relative concept. This type of VR intervention for eating disorders can also provide valuable diagnostic data to the mental health professional who is trying to understand how someone who is already so thin wants to lose even more weight. This shared image can aid in the process of joining in narrative and collaborative approaches to therapy.

Virtual Reality in Psychotherapy

123

VR for Exposure Therapy Perhaps the most intuitive use of VR in psychotherapy is to assist with exposure therapy. This is because VR ofers mental health providers a unique opportunity to calibrate a client’s experience so that it is both tolerable and therapeutic. Research on VRET has been more abundant than other uses of interactive media in psychotherapy and has focused largely on its use to treat common fears, such as fying and driving (Kaussner et al., 2020), and anxiety associated with post-traumatic stress following deployment to the military. The research related to using VRET with young people is much more limited, but emerging (e.g., Farrell et al., 2021). In a meta-analysis examining the efcacy of VRET and CBT, Opriş et al. (2011) found that behavioral therapy and CBT does far better in post-treatment results when incorporating VRET.  One of the reasons VRET has been such a popular option for fight anxiety and fear-related avoidance is because there are signifcant limits to classical exposure techniques for fear of fying. Cardos et al. (2017) conducted a quantitative review of 11 randomized studies of VRET efectiveness in fight anxiety. Consistent with the fndings of Opriş et al. (2011), the results indicate better treatment gain over time using VRET than exposurebased intervention without VR. Also focused on fight anxiety, Tortella-Feliu et al. (2011) analyzed the efcacy of three computer-based exposure treatments for fear of fying: VRET, computer-aided exposure with a therapist’s (CAE-T) assistance throughout exposure sessions, and self-administered computeraided exposure (CAE-SA). A  total of 60 participants with flying phobia were randomly assigned to VRET, CAE-T, or CAE-SA, respectively. Results indicate that all three interventions were efective in reducing fear of fying at post-treatment and at one-year follow-up. Interestingly, there were no signifcant diferences among them in any of the outcome measures, with large within-group efect sizes being found for all three treatment conditions at both post-treatment and at follow-up. A recent study examining the use of VRET to help people with their fear of driving was conducted by Kaussner et al. (2020). The pilot study used a post-treatment driving test in real trafc to examine the efcacy of VRET for 16 people with severe driving-related anxiety. Participants were given two preparatory sessions prior to the use of VRET, followed by fve VRET sessions, with the test in real trafc occurring at the conclusion of the last session. All the participants in this study were able to master driving tasks that they had previously avoided, and 93% maintained the new behavior at the second (fnal) follow-up call 12 months after the therapy had concluded.

124

Virtual Reality in Psychotherapy

The Case of Alan Alan was frst introduced in Chapter 5 when discussing video games for anxiety and OCD. When referred for therapy, he was a nine-year-old boy who was afraid of strawberries, fre drills, and zombies, with strawberries posing the biggest risk to his safety based on what OCD told him would happen if he encountered its juice or someone who had. As is often the case with OCD, exposure therapy was used to help Alan confront OCD’s demands. VR became a useful tool in this process because it allowed Alan to practice his skills in real-time without the threat of actual strawberry juice being spilled. Alan used the VR at three diferent points in the process of exposure and response prevention (ERP). The Occulus Quest was used to do this. First, he played the game Fruit Ninja on VR, a game that involves using a katana blade to slice diferent fruits and berries that are being hurled at you from an Asian-themed portal. When sliced, the fruits and berries spew juice all over the environment and, in VR, make it feel like the player is being covered in it. Playing Fruit Ninja accomplished four objectives: 1) it added a sense of humor and silliness to the process of dealing with OCD, 2) it provided an exaggerated imaginal experience, 3) it positioned Alan as the aggressor, and 4) Alan had to diferentiate between strawberries and other fruits and could discuss his response to each in therapy, assisting with deconstructing the problem. The second time Alan used VR in ERP for his fear of strawberries involved imaginal exposure using a video of strawberries that was found on YouTube. Alan started with no sound, then added the sound, which included several “juicy” moments. He also watched a homemade 3D video of his mother handling strawberries, allowing him to confront his anxiety about being exposed through her. Alan practiced the physiological sigh (two partial breaths in followed by one extended breath out; Vlemincx, Van Diest et al., 2010; Vlemincx, Taelman et al., 2011) and the GAME technique (see Chapter 5) to resist the urge to close his eyes or take the headset of. This step in ERP lasted three partial sessions, with Alan starting with fve minutes of imaginal exposure and increasing the duration by fve minutes each session. The third time Alan used VR in ERP for his fear of strawberries involved an image of a strawberry that he could actually interact with. This proved to be among the most impactful, partially because of the skills Alan had developed to that point and partially because of the interactivity the VR experience provided. Whereas Alan only had to be in the same space as the strawberry in the videos he had been watching on the VR in previous sessions, now he could be instructed to move closer to the berry and ultimately pick it up. The pacing of this became great practice for when Alan held a real strawberry, giving him a chance to space his implementation of GAME as he approached the virtual strawberry.

Virtual Reality in Psychotherapy

125

VR to Teach Meditation and Mindfulness Another common use of VR in psychotherapy for young people involves using it to teach skills in mindfulness and meditation. Young people are likely to be more engaged and learn psychophysiological self-regulation skills better when using VR because it provides a novel experience that can stimulate and confuse the senses. One recent study by Chandrasiri et  al. (2019) integrated VR with dialectical behavioral therapy (DBT) because it uses mindfulness in conjunction with behavioral and cognitive interventions. In this study, a pre-recorded mindfulness audio track was overlaid with a virtual beach environment. Participants were guided to focus on external sensations and their breath while exploring the beach for about 20 minutes. In the control group, participants listened to the audio track with their eyes closed. Not surprisingly, the participants who explored the virtual environment with their eyes open learned the skills better and retained them more consistently at post-treatment follow-up. Possible scripts for practicing mindfulness in virtual forest or beach environments are provided later in this chapter and the appendices of this book (Appendix 6). The Case of Jack Jack was a 15-year-old young man with social anxiety and fxated interests. His anxiety was most prevalent when in large groups and during tests. He reported feeling most comfortable when playing Minecraft because “I can be myself and not worry about what other people think.” Despite spending hundreds of hours building incredible modern structures in Minecraft, Jack had never experienced VR prior to coming in for therapy, and his eyes lit up when he noticed the VR headset in the ofce. “What do you do with those?” he asked. “Learn and practice new skills,” I answered. “Can we learn and practice new skills at my next appointment?” he asked. At Jack’s next appointment we decided to use VR to help him practice the mindfulness skills we had been talking about previously in therapy. Specifcally, Jack was learning to be aware of his surroundings and thoughts about his surroundings without judgment or reaction. I asked Jack if there was any place he has always wanted to go to but has not had a chance to visit yet. He chose New York City because he loves architecture, an interest fueled by his love of Minecraft. Using a program called Wander on the VR headset, Jack was transported to New York City within seconds of putting on the headset. Wander is one option for exploring parts of the world in VR (others include Google Earth VR). In Wander, the user is immediately transported to a large room, surrounded by windows with views of mountains. Above a large freplace in the center of the room is

126

Virtual Reality in Psychotherapy

a map that, when pointed to, would populate the user’s headset with a three-dimensional scene in that location. The scene could be navigated using a hand control on the Occulus Quest and included the people and activities that were present at the time the video was recorded. Jack’s experience began in Times Square, where he looked up and explored his surroundings for a moment before moving to another area of Manhattan. Jack was instructed to spend about two minutes on each street that he chose to travel to, taking in the scenes and noticing the architecture without becoming preoccupied with how to build it in Minecraft, a distraction that often made it difcult for him to enjoy most visits to new places. Jack was able to notice the people, buildings, beauty, and chaos, all at his own speed and in his preferred way. Despite the absence of New York City sounds or smells, Jack was able to recollect and recreate these sensations in his mind when he passed by a large crowd or a hot dog stand. Unexpectedly, Jack learned that he tends to remember details and other information about his surroundings better when he is looking slightly up instead of down, or even straight ahead. In this way Jack was able to use VR as a mirror, similar to how we use biofeedback in therapy to help people learn new things about themselves that were unclear until the information was made available. Jack’s story has become a common one, with people choosing a variety of VR games and experiences to notice new things about the way they exist. Beat Saber, a game that involves slicing diferent color shapes as they approach you at high speed to music is a favorite choice for many young people who are trying to learn mindfulness skills to improve focus and attention. The game requires the player to “connect” with the music and tune out distractions. In psychotherapy, young people will often set goals for themselves to beat their previous score despite increasing distractions from the mental health provider, siblings, or other group members (if being used in group therapy). Guided Imagery and VR: An Example While writing this book I have been working with a start-up called XR Realms to develop VR environments to help people, including young people with cancer, cope better with pain. The environments included in the project are a virtual forest and beach, each with the option to experience them while listening to scripts intended to assist with general meditation or learning mindfulness skills. The scripts used for these purposes were created to support processes and skills, such as abdominal breathing, grounding, and noticing thoughts and sensations without judgment. Conceivably, these same scripts or a version thereof could be read to a client during a session using a more generic forest or beach scene, like one found in the VR game Wander mentioned previously in this chapter. As a starting point for those reading this book, the forest and beach scripts intended to assist with meditation while using the

Virtual Reality in Psychotherapy

127

VR environments created by XR Realms are included next. Additional scripts are available in the appendices (Appendix 6).

Forest Scene Take this moment to settle yourself in whatever way you know how. Inhale through your nose, and exhale through your mouth (pause 5 seconds). Repeat this again, inhale through your nose and exhale through your mouth (pause 5 seconds). Pay close attention to your body—notice any areas of tension. Notice any unresolved energies (approximately 26 seconds total read time). (Pause 10 seconds) Start with the top of your head, noticing any tension or discomfort. Move down through the neck and onto the shoulders, through the arms, and onto the chest and core. Pause at the core. Sit here for a moment while continuing to focus on your breathing (approximately 18 seconds total read time). (Pause 10 seconds) Take another deep breath. Notice your legs beneath you, down to the calves, onto your feet and through your toes. Feel the weight of your body as it connects to the earth beneath you. Imagine that your feet are roots, growing into the ground, making you one with the forest. Continue breathing through your heart area as you come into this moment (approximately 26 seconds total read time). (Pause 10 seconds) Look around the forest and explore the various colors, the intricacies, and the beauties that make up nature (pause fve seconds). Notice how the branches dance in the wind. Allow your body to feel the gentle sway (approximately 18 seconds total read time). (Pause 10 seconds)

Figure 10.1 Image provided with permission of XR Realms

128

Virtual Reality in Psychotherapy

Bring your attention to the sensation of air on your skin. Notice any breeze or lack thereof. Are you warm? Cool? Just right? Simply notice (approximately 10 seconds total read time). (Pause 10 seconds) Pay attention to the sounds of the forest around you. Notice the sound of water trickling in a stream? Perhaps you hear birds chirping in the trees or the wind passing through leaves. Focus on the sounds that you most appreciate in that moment (approximately 16 seconds total read time). (Pause 10 seconds) Let your mind go in whatever direction it needs to without judgment. Continue breathing deeply through your heart area (approximately 8 seconds total read time). (Pause 10 seconds) On the next exhale, focus on your sensations, including those outside of the forest—your feet on the ground, the temperature of the room, the VR headset. You can choose to focus on any of these sensations. You are in control and can choose to stay or leave the forest as you wish (pause 5 seconds). Soak up this moment so you can appreciate the simplicity of the forest and awareness of your body’s energy as you proceed through your day (approximately 32 seconds total read time).

Beach Scene

Figure 10.2 Image provided with permission of XR Realms

Virtual Reality in Psychotherapy

129

As you begin this practice, take a moment and congratulate yourself for being here (pause 5 seconds). You are taking this time to be present. In these frst couple of moments, allow yourself to feel where you are in the mind and body (pause 5 seconds). Begin to scan the body for any unresolved energies without placing judgment, allowing the mind to go in whatever direction it chooses (pause 8 seconds). Notice your mood, your emotions (pause 8 seconds). Acknowledge what is being felt and allow that feeling to exist without judgment (approximately 60 seconds total read length). (Pause 10 seconds) Gently begin to notice your breath (pause 8 seconds). On your next inhale, send your breath into your abdomen (pause 4 seconds), flling it with air as you feel your diaphragm rise into your chest (pause 4 seconds). As you exhale, soften your collar bones, ribs, and belly (pause 4 seconds). Continue breathing through your heart area as you lean into this moment (pause 20 seconds). Continue to allow your mind to exist without judgment; you are in control (approximately 62 seconds total read length). (Pause 10 seconds) As you settle into your breath, bring your attention to your surroundings (pause 8 seconds). Listen to the sound of the ocean (pause 8 seconds). Take note of the water (pause 4 seconds). How does it sound as it moves up the beach? (pause 5 seconds) Does the sound change as it moves back out? (pause 6 seconds) Hear the waves as they fold into themselves and crash against the beach (approximately 45 seconds total read length). (Pause 10 seconds) Notice your surroundings with a renewed sense of appreciation (pause 4 seconds). Let yourself feel the warmth of the sun (short pause). Feel the sand under your feet. Perhaps you can feel a light breeze and smell the salty air (pause 4 seconds). Give yourself space to experience and connect with these sensations (pause 10 seconds). Allow yourself to just be at your beach for a while (approximately 40 seconds total read length). (Pause 10 seconds) See the waves wash up onto the sand (pause 4 seconds) and then recede back toward the ocean (pause 3 seconds) washing up (pause 3 seconds) and fowing back down (pause 3 seconds). Enjoy the ever-repeating rhythm of the waves (pause 4 seconds). Send your gaze toward the greenery (pause 3 seconds). Pay special attention to the intricate colors (pause 3 seconds); the greens (pause 3 seconds); the blues (pause 3 seconds). Are there other colors that your eyes and mind are drawn too? Notice and embrace the beauty that surrounds you (pause 5 seconds) (approximately 55 seconds total read length). (Pause 10 seconds) Inhale and recognize the beauty of this moment (pause 4 seconds). On your exhale, try to evoke a feeling of appreciation (pause 6 seconds). Allow

130

Virtual Reality in Psychotherapy

yourself to feel relaxed in whatever way you know (pause 6 seconds). Stay in this moment and allow all your stresses to drift away with the water (pause 6 seconds). With each new wave comes an opportunity to discharge stress and regain strength. You are resilient (approximately 40 seconds total read length).

Virtual Sessions Virtual sessions are also becoming a popular approach for doing psychotherapy, especially group work, with people in rural settings or with social anxiety. Using VR, clients can create avatars to represent themselves and occupy a shared virtual therapy space in real time with other group members. The technology can capture subtle gestures and body posture that are often missed in other forms of telehealth. It also provides the option of going to therapy as one’s “best self,” whether it be an idealized version of the actual self or a character that represents something about the self that the client wants to communicate. Even though technology is advancing rapidly and 5G is making virtual sessions more accessible, issues related to client confdentiality and clinician reluctance have resulted in only limited examples of what is possible. As with many ideas in this book, the COVID-19 pandemic has amplifed the importance of resolving these issues. The Case of Jonny Jonny was a 12-year-old with ASD who was referred to therapy to assist with social-emotional issues that were impacting academic functioning. He was not happy to be in therapy and clear in his intent to make the process as difcult as possible. His father, who attended every session, reported that Jonny had seen two mental health providers in the past and was told by both that they did not think they could help him. Jonny’s father attributed this to his high intelligence, stating that, “Jonny can see through the ‘how does that make you feel?’ BS.” At the frst appointment, Jonny said, “I only came here at all because my dad told me that you play video games with your clients.” Challenge accepted. After Jonny’s frst three appointments in the ofce, the COVID-19 pandemic prevented us from seeing each other “in person” again for nearly six months. As with most clients during that period, Jonny’s frst couple therapy appointments after the pandemic hit were conducted on the computer (we used an encrypted version of Zoom). During one appointment on Zoom, Jonny asked if he could practice mindfulness skills as he did in the ofce, using his Occulus Quest VR headset to do so. “Why not?” And so Jonny proceeded to put on his VR headset while I watched through the computer. “Where would you like to go today?”

Virtual Reality in Psychotherapy

131

I asked. What followed was a lesson on a game called Rec Room that captured my attention enough to agree to join him in that space, virtually. According to their website, Rec Room is “the best place to build and play games together. Party up with friends from all around the world to chat, hang out, explore millions of player-created rooms, or build something new and amazing to share with us all.” Jonny proceeded to invite me into his private virtual rec room that only was accessible to himself and those he invited in. In the game, we were each represented by a simple, unrealistic avatar whose head was disconnected from its body. Nonetheless, the experience felt oddly “real” as we shot baskets on a mini basketball hoop while discussing his struggles at school. It defnitely felt more like seeing him “in person” than when we were only using the computer as our interface. After two appointments using Rec Room, Jonny decided that he wanted me to join him in the community area of the game, where he interacted with other players from around the world. After establishing “game rules” related to confdentiality and his goals in therapy (e.g., how he would introduce me, what was ok to talk about), we walked through a magic door in his private rec room and were transported to a seemingly enormous space where hundreds, if not thousands, of other players were talking and playing games. “What a perfect place to practice social skills!” The next several minutes in the community rec room were spent getting a tour and getting introduced to Jonny’s friends in the game. Prior to entering the environment, Jonny had agreed to focus on “listening to what his friends had to say and responding with either a related question or comment.” The frst avatar we encountered provided the perfect opportunity. She said, “Jonny, I just started a new world in Minecraft. I am going to build a treehouse like you have.” Jonny was quick to respond, “You could never build a treehouse as cool as mine!” I  pulled Jonny aside after the encounter and asked him what he was feeling when he said that. “Having a cool tree house is my thing,” he said. “She stinks at building and shouldn’t be telling people that she can build a treehouse like mine.” “What would happen if she said that?” I asked. “Other people would think that I  stink at building too,” Jonny replied. “Just like her.” Jonny and I were able to immediately transport our avatars to his private rec room to discuss the situation. “What was the frst thing you thought when your friend told you she was building a treehouse like yours?” I asked. “I got angry because everyone knows that treehouses are my thing when we play Minecraft together” Jonny replied. “What are some reasons why your friend would want to tell you that she is building her own treehouse?” I asked. Jonny proceeded to list several reasons, some “negative” and some “positive.” Ultimately, Jonny agreed that one way to have experienced that situation was to be fattered that his friend wanted to build something as cool

132

Virtual Reality in Psychotherapy

Figure 10.3 Rec Room is one VR game worth trying when doing telehealth

as what he had built. We decided to practice looking for the “positive intent” in his friend’s comments and returned to the community area in Rec Room. In short time there are likely to be dozens of environments, like Rec Room, where meeting virtually with a client in a completely customizable setting is both possible and capable of enhanced therapeutic capacities (e.g., built-in experiences and virtual tools). Ideally, an environment created for the purpose of conducting psychotherapy will be developed that provides enhanced security and evidence-based options for customization. Such an innovation, combined with the decreasing cost of VR and emergence of the “Metaverse,” is sure to revolutionize psychotherapy for young people for many years to come.

Common Questions and Answers Question Where can I  learn more about using VR in psychotherapy for young people?

Answer Because VR is already relatively popular in mental health treatment, there are more resources available for better understanding and

Virtual Reality in Psychotherapy

133

implementing VR in psychotherapy than other forms of interactive media. One example is Rizzo and Bouchard (2019), whose book Virtual Reality for Psychological and Neurocognitive Interventions explores VR in both its current therapeutic forms and its future potential to transform medical and mental health–related felds. Specifcally, it details applications of VR across psychological and neurocognitive conditions, including: • • • • •

Anxiety disorders and OCD Post-traumatic stress disorder (PTSD) Developmental and learning disorders (including ASD) Assessment of and rehabilitation from stroke and traumatic brain injuries Assessment and treatment of substance abuse

Question How do I know what VR headset to purchase for my practice?

Answer VR technology is advancing as, if not more, rapidly than any other form of interactive media. Advancements such as 5G are making VR more accessible and powerful than ever. While most non-phone-based VR headsets will provide you with a useful tool in therapy with young people, there are some considerations that can maximize the client experience and simplify the use of VR for the mental health provider. Perhaps the most important consideration is portability, as many VR systems still require a gaming PC to operate. For clinical purposes, stand-alone headsets, such as the Oculus Quest or HTC Vive Pro Eye, tend to be far more useful than wired systems, with the Oculus being far more afordable, but less versatile, than the HTC. Other options are the Pico and PlayStation VR, ofering simple and efective functionality, and enhanced gaming capabilities, respectively. I currently use the Pico because it has contacts that are especially easy to clean and sanitize.

Therapist Missions •

Invest in VR goggles for the ofce and start experiencing the future!

References Bomba, M., Alibert, J., & Velt, J. (2021). Playing and virtual reality: Teleanalysis with children  and adolescents during the COVID-19 pandemic.  The International Journal of Psychoanalysis, 102(1), 159–177.

134

Virtual Reality in Psychotherapy

Cardoş, R., David, O.,  & David, D. (2017). Virtual reality exposure therapy in fight anxiety: A quantitative meta-analysis. Computers in Human Behavior, 72, 371–380. Chandrasiri, A., Collett, J., Fassbender, E., & De Foe, A. (2019). A virtual reality approach to mindfulness skills training. Virtual Reality, 24(1), 143–149. Diemer, J., Pauli, P., & Mühlberger, A. (2015). Virtual reality in psychotherapy. International Encyclopedia of the Social & Behavioral Sciences, 25, 138–146. Farrell, L., Miyamoto, T., Donovan, C., Waters, A., Krisch, K.,  & Ollendick, T. (2021). Virtual reality one-session treatment of child-specifc phobia of dogs: A controlled, multiple baseline case series. Behavior Therapy, 52(2), 478–491. Grochowska, A., Wichniak, A., & Jarema, M. (2019). Virtual reality—a valuable tool to advance treatment of mental disorders. Archives of Psychiatry and Psychotherapy, 21(1), 65–73. Irvine, K., Irvine, A., Maalin, N., McCarty, K., Cornelissen, K., Tovée, M., & Cornelissen, P. (2020). Using immersive virtual reality to modify body image. Body Image, 33, 232–243. Kaussner, Y., Kuraszkiewicz, A., Schoch, S., Marke, P., Hofmann, S., Baur-Streubel, R., Kenntner-Mabiala, R.,  & Pauli, P. (2020). Treating patients with driving phobia by virtual reality  exposure therapy—A pilot study.  PLoS One, 15(1), Article e0226937. Opriş, D., Pintea, S., García-Palacios, A., Botella, C., Szamosközi, T., & David, D. (2011). Virtual reality exposure therapy in anxiety disorders: A  quantitative meta-analysis. Depression and Anxiety, 29(2), 85–93. Riva, G. (2005). Virtual reality in psychotherapy: Review. CyberPsychology & Behavior, 8(3), 220–230. Rizzo, A., & Bouchard, S. (2019). Virtual reality for psychological and neurocognitive interventions. Springer. Rothbaum, B., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., Pair, J., Hebert, P., Gotz, D., Wills, B., & Baltzell, D. (1999). Virtual reality exposure therapy for PTSD Vietnam veterans: A case study.  Journal of Traumatic Stress, 12(2), 263–271. Rothbaum, B., Ruef, A., Litz, B., Han, H., & Hodges, L. (2003). Virtual reality exposure therapy of combat-related PTSD: A case study using psychophysiological indicators of outcome. Journal of Cognitive Psychotherapy, 17(2), 163–177. Tortella-Feliu, M., Botella, C., Llabrés, J., Bretón-López, J., del Amo, A., Baños, R., & Gelabert, J. (2011). Virtual reality versus computer-aided exposure treatments for fear of fying. Behavior Modifcation, 35(1), 3–30. Vlemincx, E., Taelman, J., De Peuter, S., Van Diest, I.,  & Van Den Bergh, O. (2011). Sigh rate and respiratory variability during mental load and sustained attention. Psychophysiology, 48(1), 117–120. Vlemincx, E., Taelman, J., Van Diest, I., & Van den Bergh, O. (2010). Take a deep breath: The relief efect of spontaneous and instructed sighs.  Physiology  & Behavior, 101(1), 67–73.

Chapter 11

Avoiding Nature Deficit Disorder

In some ways, an argument could be made that video games are “natural” because they are created by and used by humans. Where do we draw the line for what is and is not natural? As a species, humans tend to make new and “better” things each year, whereas other species (e.g., bees, birds) tend to follow the same plan every time they build something new (e.g., hive, nest). Video games certainly look much diferent than they did 35 years ago when Atari was popular. Is this what makes them unnatural? Their rapid, “unnatural” progression? What happens when virtual reality becomes as realistic as real life? Will it then be more or less natural? The current chapter will not try to answer any of these questions, only report briefy on what we think we know currently about nature’s infuence on development and ofer ideas for how to encourage young gamers to go outside and enjoy it.

Nature Deficit Disorder Defined In his national bestselling book Last Child in the Woods, Richard Louv (2019) defned nature defcit disorder as “a way to help us better understand what many children (with attentional issues) experience, whether or not they have been diagnosed with attention-defcit hyperactivity disorder.” Louv (2019) argues for this concept based on the evidence that many young people with attentional issues spend less time in nature and do better when their time outdoors and in naturalistic environments is increased. In the current chapter, the term “nature defcit disorder” is not being used in a scientifc or clinical sense. In fact, the opposite is true—it is being used half optimistically, with the intent to bring proper attention to the widely held belief that we are connected to the world (and others in it) in ways that cannot be replaced by video games and interactive media. I fnd the use of this non-clinical term preferable to the label ADHD in describing young people who are clearly able to focus when engaged (e.g., when playing video games) but not when at school or being asked to engage in a DOI: 10.4324/9781003222132-11

136

Avoiding Nature Deficit Disorder

nonpreferred task. Ultimately, for the purpose of this chapter, the use of the term nature defcit disorder will be more valuable for creating a catchy title than anything else.

The Argument for Nature There is a growing body of literature suggesting that exposure to nature is important for development. The more technology advances, the more we are becoming cognizant of the need to spend adequate time in nature. Wells and Evans (2003) assessed the degree of nature in and around the homes of rural children in grades three through fve. They found that children who were exposed more to nature as part of their daily lives were less prone to conduct disorders, anxiety, and depression. These children also rated themselves higher on a global measure of selfworth. Similarly, Bagot et al. (2015) found that green playgrounds are more restorative than artifcial or human-made playgrounds. Not surprisingly, considering these fndings, Duncan et  al. (2014) found that children engaging in green exercise have lower blood pressure than those not exercising in nature. Gill (2014) completed a systematic review of the research between 1990 and 2011, showing what benefts nature has for children. He focused on the most rigorous studies of children ages 12 and under that took place in woodlands, urban green spaces, and outdoor “wild” spaces near urban areas in the UK. Ultimately, Gill (2014) reported on 61 studies, suggesting potential benefts including health benefts, well-being, cognitive benefts, social skills, emotional and behavioral benefts, and attitudinal benefts. Of particular interest to many reading this book are: 1) child contact with nature increases connection to place and environment, 2) living near green spaces is associated with increased physical activity, and 3) children who have more contact with nature experience fewer symptoms of ADHD and improved emotion regulation. Mygind et al. (2019) conducted a similar systematic review of the literature spanning 2004–2017 that examined the evidence for benefts of immersive nature experience on children and adolescents’ mental, physical, and social health. Their results also spoke to the importance of staying connected to nature as a young person. The childhood link between outdoor activity and health is evident, despite its complexity. The Center for Disease Control (CDC) reports that the US population of children between the ages of two and fve years that are overweight increased by approximately 36% in the last decade of the twentieth century. Pediatricians are now suggesting that today’s generation of Americans may be the frst to die at an earlier age than their parents since World War II. The World Health Organization (WHO) warns that inactivity is a global health problem.

Avoiding Nature Deficit Disorder

137

Many of my clients have limited interest in learning to drive anymore because they can access almost anything they want at the palm of their hands. Video games, while helpful as a form of recreation and when used in the ways suggested by this book, present one possible antecedent to sedentary behaviors in young people. For this reason, it is incumbent on mental health providers to help caregivers monitor screen time, with two hours daily being the default amount of time recommended, but a more nuanced approach being suggested by the most recent meta-analysis of the research (Ophir et al., 2021). I have found there to be great variability in how much screen time diferent young people can balance with their other life activities and still function at an exceptionally high level.

Exercise, Activity, Anxiety, and ADHD There is a growing body of evidence to suggest that exercise and activity can be equally as important to preventing/treating anxiety or attention defcit hyperactivity disorder (ADHD) as taking one’s medicines (Ratey & Loehr, 2011). According to Samani and Heath (2018), brief bouts (10 minutes) of exercise can spark bursts of brain power. In their study, 14 healthy college students: 1) sat quietly and read magazines or 2) did 10 minutes of moderate-to-vigorous physical activity on a stationary bicycle. Immediately after the 10 minute task (reading or exercise) the researchers used eye-tracking equipment to gauge executive control. Those who exercised for 10 minutes had signifcantly better executive performance. Likewise, in an unpublished study of 120 children grades four through eight at the Charleston Progressive Academy, 40 minutes of exercise (jumping rope, Dance Dance Revolution, basketball, or pogo stick jumping) at the beginning of the day resulted in improved focus throughout the day, especially immediately after morning activities. In the case of ASD, two separate studies looking at yoga (Rosenblatt et al., 2011) and martial arts (Bahrami et al., 2016) demonstrated improvements with stereotypic behaviors, attentional problems, and adaptive skills. Blumenthal et al. (2007) found that supervised exercise was more helpful than medication to treat depression. Finally, there were over 120 articles published in the 2010s examining the relationship between physical activity, physical ftness, and academic performance among children. The research is clear and needs to be considered when working with gamers, who often spend less time engaged in physical activities than young people who choose to spend their time playing sports or other similar extracurriculars.

Gaming’s Impact on Young People’s Exposure to Nature Although the research on the relationship between time spent gaming and time spent in nature is limited, it is certainly reasonable to assume

138

Avoiding Nature Deficit Disorder

that most time spent gaming is time that could have and probably would have been spent in nature prior to the rise of video games. In his book Media and Youth: A Developmental Perspective, Steven Kirsh (2010) reported on hundreds of studies examining the relationships between media and the lives of youth. He included research on media and academic efects; the medical social benefts of media use; media and stereotyping; media infuences on obesity, body image, and eating disorders; as well as the role of media in youth drug use, sex, and violence. Overall, the research Kirsh (2010) reported on suggested only a minimal infuence of media on variance in child development that could be mitigated by protective interventions (e.g., putting limits on screen time, co-consuming content, providing education on what and how much content is safe to consume). Balancing time spent on gaming with time spent in nature is another example of how mediation can be used to reduce the potential negative efects of media. Taking the additional time to explain the importance of nature and our connection to it will further reinforce this reduction in negative efects while promoting the already evidence-based benefts of nature on development.

Technology in Nature As this is a book about how to use video games in psychotherapy with young people, the current section focuses on ways that this can be done in the great outdoors! Screens are more accessible than ever. Some of the most popular games are now available on smartphones and with the emergence of new technology, such as 5G and improved cell phones, it is conceivable that most video games will be created for use in this (mobile) form in the future. For now, some of the best games, apps, and other ideas I have discovered over the past decade for gaming outside are listed and described here. Pokémon Go There was a period in the summer of 2016 when all my clients had adequate vitamin D levels. It was the year that Pokémon Go came out, and many of my clients who were previously spending as much time as possible in front of a screen in their basement or bedroom were now on the hunt for Pokémon in some of the most unexpected places. Pokémon Go used augmented reality to create a game that allowed players to travel their towns in search of Pokémon to capture, collect, and trade. The game was a brilliant concept that had the capacity to strategically place Pokémon in and around businesses to bring in more foot trafc. It could not fail. Unfortunately, it had inherent issues that often caused it to crash and required substantial back-end support that could not be maintained.

Avoiding Nature Deficit Disorder

139

Still, the game provides a fun way to get gamer clients outside on a nice day and, like other Pokémon games, it ofers seemingly endless metaphors for externalizing problems and clarifying strengths and abilities. Geocaching Geocaching is an app-based scavenger hunt that helps users fnd their way to hidden trinkets (placed in “geocache containers”) that others have left behind. Like Pokémon Go, geocaching combines screen time with nature to create an experience that can shed light on a client’s strengths and constraints to moving forward. In the mental health provider role, when using geocaching with a client the emphasis is on identifying patterns and meaning in a client’s decisions when searching for a geocache. As with Pokémon Go, the use of developmentally appropriate play therapy skills can also be helpful when geocaching with a client. For example, refecting content (e.g., “You are careful to always bring something to leave behind in the container”) and refecting meaning (e.g., “It must be important to you that other people who do this have a good time”). Most areas participate in geocaching, which is available for free as an app. Real-Life Minecraft Young people do not tend to build treehouses and forts in the woods as much as they did 30 years ago. Why put so much time and efort into nailing boards when you can press a few buttons and build some of the most intricate structures in Minecraft? Ironically, some of the same young people who are averse to building something outside because they would rather play Minecraft are likely to jump at the opportunity when Minecraft concepts and metaphors are employed in the great outdoors! Cardboard boxes can be a great replacement for digital building blocks, especially when paired with wrapping paper or other ways to turn them into the materials available to build with in Minecraft (e.g., wood, stone, wool). Challenging a client to design an outdoor fort by using Minecraft can be an excellent way to help young people experience how transferable their gaming skills are to real-life tasks. Challenging a group to work together to build something can be an excellent way to teach skills in socialization, cooperation, problem solving, and perspective taking. Role Play Dressing as one’s favorite video game character and engaging in role play is a common way for many gamers to connect outside of the screen. One need look no further than YouTube to fnd thousands of examples of this

140

Avoiding Nature Deficit Disorder

type of role play. In psychotherapy, video game role play can be used to: 1) practice new skills, 2) reauthor past experiences, and 3) communicate difcult concepts. Much of this work can easily occur in nature, leveraging its potential benefts to enhance creativity and facilitate the restorative process. An example of what this might look like is described next. This particular role play occurred in individual therapy in a grassy area with a few locust trees behind the therapy ofce. The client (Mike) was diagnosed with OCD (which he named Bowser) that told him that he had an invisible cord attached to his back that could not be tangled by leaving through a diferent door than he had entered. The same cord prevented him from walking around trees or other things that it might get wrapped around. He agreed to challenge this compulsion when the added fun of pretending to be Mario and Bowser from Super Mario Bros. was added to the equation. An approximate script of what ensued is provided next. Dr. Rice (wearing a cardboard box as a turtle shell): “I am Bowser, and the only way to defeat me is to use your cord to wrap me around that tree!” Mike (wearing a pretend mustache and hat): “I am Mario, and I won’t let you continue to keep me from doing fun things because of this stupid cord!” Mike then proceeded to run circles around both Bowser (Dr. Rice) and the tree. Dr. Rice (still wearing the cardboard box as a shell): “I’m stuck! If you don’t let me go, something bad will happen! I promise!” Mike (his mustache now closer to his chin than his nose): “How are you going to do anything to me if you are stuck to a tree?” Mike and I then spent approximately 15 minutes sitting near that tree (What else could I do? I was tied up by his cord), celebrating his success and discussing how he could continue to use his cord against OCD instead of letting it control his life. Mike practiced the GAME approach described in Chapter 5, along with his abdominal breathing. We also brought the Nintendo Switch outside with us so that he could play Super Mario Bros. while he worked through the anxiety caused by leaving his cord wrapped around the tree. Ultimately, we walked back to the ofce together where his parents waited with scissors to metaphorically cut Mike’s cord and celebrate his accomplishment (with cupcakes). During the celebration, Mike’s parents, Mike, my intern, and I took turns completing the unfnished sentence, “Mike is going to defeat Bowser because . . .” Among Us Among us is a popular app-based video game where you control a space cadet (either a crew mate or an imposter) in navigating a space station

Avoiding Nature Deficit Disorder

141

without being killed (or without being identifed as the killer if in the imposter role). The game allows strangers to join and play with each other online and is a mobile game that can be played outdoors with WIFI or data. Among Us is also especially compatible with outdoor or active play by removing the screen and asking young people in a small group to physically play out the role of crew mate or imposter. As the crew mate, group members are instructed to keep an eye out for the imposter and try to avoid being killed. As the imposter, group members are instructed to wink at a crew mate without letting others see you or guess that it was you who did it. When winked at, a crew mate will pretend to expire in whatever way they fnd amusing and appropriate. Once the expired crewmate is identifed by another “living” crew mate, a meeting is called, and the remaining players vote on who they think the imposter is. Playing Among Us outside can be a great way to help clients in groups practice social skills, teamwork, and perspective taking. For added therapeutic value, the meetings to discuss the killing of a crew mate can include a quick check-in on client experiences or lessons on mindfulness that can help them efectively transition from the excitement of running around outside to the tension and seriousness of voting out a crew mate. Outdoor Local Play on Portable Devices Perhaps the easiest and most straightforward way to get young gamers to go outside is by using mobile devices like the Nintendo Switch. One feature of the Switch that allows for groups to take gaming outside and still maintain a collaborative and interactive environment is called local play. Local play is the ability for multiple Switches to connect to each other regardless of WIFI access. In therapy, gamer clients can use local play to play collaborative games (e.g., Lego series) while following instructions like the following: • • • • • • •

Notice a smell in nature Notice a sound in nature that captures your attention Pay attention to if there is a breeze while you are playing Try to hear something you normally wouldn’t be able to hear while you are playing (e.g., sap traveling through a tree) Try to pay attention to things in the game that remind you of things in nature and vice versa What are some things in nature that you wish you could tune out or turn of while you play? Are there things in the game that you wish you could tune out or turn of when you are playing it outside? How come?

142

Avoiding Nature Deficit Disorder

Then, during planned pauses from play, clients can report on their observations and preferences. This technique can be a great way to teach grounding and other skills that promote improved focus, performance, and psychophysiological self-regulation. Zombies, Run! Some young people who are already moderately motivated to begin an exercise routine fnd just the extra motivation they need by using apps like Zombies, Run! In Zombies, Run! one’s smartphone and earbuds place them right in the middle of a zombie epidemic, charged with running to one of humanity’s last remaining outposts to help gather supplies and rescue survivors. Users can walk, jog, or run anywhere in the world while being fed missions through their earbuds (missions interrupt music). Runners must speed up when told that zombies are chasing them. The more time spent using the app, the more supplies a runner earns to build up their base. As with other health apps, Zombies, Run! also helps tremendously with monitoring client progress and adherence to therapy. Nature-Based Video Games Big Bass Fishing was one of my favorite games to play at arcades as a child. It is also a great example of a “nature-based” video game because it intends to bring an outdoor activity (i.e., fshing) into the living room. On several occasions I  have experienced formerly “outdoors averse” young clients who developed a relationship with nature, not by forcing themselves to go outside and spend less time in front of screens but allowing their screen time to inform their experience of the outdoors. In fact, for many young people video games can provide a pathway to the confdence necessary to do things in the non-digital world. The use of driving simulators to prepare people for the road is a great example of how this works and is backed by research (e.g., Kaussner et al., 2020). In the made-to-stream television show on the Disney Network called Mighty Ducks; Game Changers, a newly created team of misft hockey players called the “Don’t Bothers” were looking for a goalie for their team. Rather than go to the nearest ice rink to fnd a player, the team leaders located their future goalie by tracking down the best online video game hockey player they could fnd. Like the case of Mick described next, the goalie they found playing online hockey lacked the motivation and confdence to play hockey in real life until a couple fellow misfts reminded him that his video game play demonstrated many of the same skills and abilities required to play in real life.

Avoiding Nature Deficit Disorder

143

The Case of Mick One of my favorite case examples involving the use of a nature-based video game to both promote a relationship with nature and address a symptom of mental illness is Mick. Upon referral, Mick’s mother was concerned about his activity level and believed that he was depressed because he spent so much time in his bedroom playing video games. Mick had also developed a hoarding behavior that resulted in an exceptionally messy bedroom and school backpack that was bursting at the seams with paperclips, garbage, and other items he chose to pick up of the ground during the school day. Mick had a hard time answering the crystal ball question (i.e., “What will things look like when they are even better than they are now?”) during his frst psychotherapy appointment. His mother also struggled with this question but was insistent that Mick stop hoarding and get out of his room every now and then. Because they had difculty with the crystal ball question, I asked them if they could remember a time when things were better, before Mick started hoarding and stopped spending time with the family. They were both quick to respond, saying that they had family with a lake house that they would often visit for weeks at a time when Mick was younger. When asked what he liked about the lake house, Mick said that he enjoyed fshing. I was surprised by this answer because Mick made it clear to me earlier in the session that he hated the outdoors. At Mick’s next session I asked him if he wanted to talk while we played some video games. In preparation for the appointment, I  had set out about fve games, four of them being what I perceived to be some of the most boring games imaginable, and one of them being Big Bass Fishing. As predicted, Mick chose to play Big Bass Fishing. Luckily, he also enjoyed it. For the next couple sessions, I spoke with Mick about the cognitions involved with his hoarding while we played Big Bass Fishing together. Of course, he crushed me every time we played, to which I would say, “Are you this good at this game because of your time fshing at your family’s lake house?” and “It looks like you haven’t lost your touch!” About fve sessions in, I prepared a fshing game (not a video game) for Mick to play in the ofce. It involved casting a real fshing rod with a large piece of extra-sticky double-sided tape at the end of the line. With encouragement from myself and his mother, Mick agreed to set a pile of 30 hand-selected items that he had hoarded in his backpack on the other side of the room. He then stood on the other end with the fshing rod and was instructed to try to catch 10 things that he wanted to keep. Despite his wish to keep it all, he agreed to the challenge, and as expected, he caught all but one of the things he had decided he needed to keep in his backpack. Our next several sessions were spent splitting

144

Avoiding Nature Deficit Disorder

time between playing Big Bass Fishing (as a warm up) and casting for hoarded items in the ofce. This continued until Mick had only one pocket in his backpack that was reserved for hoarded items. When Mick started to make progress on his hoarding, his mother started to focus more of her attention on his screen time and her concerns that he spent too much time in his bedroom. Having been practicing his casting on Big Bass Fishing and in the ofce for the past several sessions, I hypothesized that Mick might feel an urge to try fshing for real again. I brought some fshing rods to our next scheduled appointment and asked him if he would be interested in walking with me to a drainage pond near the therapy ofce to test this hypothesis. Mick continues to be an avid gamer, but is now also an avid fsherman, with several fshing derby trophies to his credit. He no longer engages in hoarding (except bait and fshing gear), and his mother is no longer concerned about his screen time.

Common Questions and Answers Question When should I consider incorporating more nature in my client’s treatment plan?

Answer The literature suggests that young clients diagnosed with ADHD, depression, ASD, and anxiety are likely to beneft from increased contact with nature (if contact with nature is determined to be inadequate to begin with). One good rule of thumb is to try to encourage at least as much time spent in nature as playing video games or watching YouTube videos. This strategy can serve the dual purpose of formalizing an expectation to spend some time being active (preferably in nature) and motivating the client to spend more time being active in nature (to earn more screen time).

Question What is nature-based therapy, and how can I learn more about it?

Answer Nature-based therapy is one term used to describe the integration of nature and (mental health) therapy. Other overlapping terms are ecotherapy and adventure-based therapy, which include subcategories such

Avoiding Nature Deficit Disorder

145

as animal-assisted therapy and forest-bathing therapy. As the evidence for the benefts of a connection to nature grow, these approaches are building steam and even fnding homes in graduate schools that train mental health professionals. Harper et al.’s (2019) book Nature-Based Therapy; The Nature Fix (Williams, 2018); and Ecotherapy (Jordan & Hinds, 2016) are three excellent resources for mental health providers interested in learning more about this growing movement. One of my current goals is to purchase some property in the Adirondacks of New York where I can run camps in nature with young gamers using video game–inspired outdoor activities like those described in this chapter. Talk about two ends of a child therapy spectrum.

Question How do I know if my client is following through on missions to spend more time in nature and/or increase physical activity?

Answer Tracking progress and adherence to therapy is almost always a challenge. Fitbits and other wearables can be great ways to track movement goals, but it can be more difcult to track time spent in nature. One way that I have found useful is to ask clients to take pictures when in nature or collect items from nature that they can bring back to the therapy ofce as evidence that they completed their missions. Not surprisingly, many clients who were given these types of missions eventually developed an interest in things like nature photography. I even had one client who started collecting bugs, ditching his Nintendo for hours a day to fnd some of the rarest bugs in his area. Although Pokémon Go had not even been released yet, this client chose to compare each bug to his favorite Pokémon and organized his collection using a large Pokémon binder. Of course, we found meaning in every bug collected and name chosen!

Therapist Missions • • •

Take a hike! Try geocaching—fnd the geocaches closest to your psychotherapy ofce to prepare for excursions with clients. Hug a tree! Trees can teach us a tremendous amount about relationships. As stationary life forms, they are amazingly intelligent when it comes to keeping things that are harmful away and pulling things that are benefcial close. Tree-assisted therapy should be a thing.

146

Avoiding Nature Deficit Disorder

References Bagot, K., Allen, F.,  & Toukhasati, S. (2015). Perceived restorativeness of children’s school playground environments: Nature, playground features and play period experiences. Journal of Environmental Psychology, 41, 1–9. Bahrami, F., Movahedi, A., Marandi, S.,  & Sorensen, C. (2016). The efect of Karate techniques training on communication defcit of children with autism spectrum disorders.  Journal of Autism and Developmental Disorders, 46(3), 978–986. Blumenthal, J., Babyak, M., Doraiswamy, P., Watkins, L., Hofman, B., Barbour, K., Herman, S., Craighead, W., Brosse, A., Waugh, R., Hinderliter, A., & Sherwood, A. (2007).  Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine, 69(7), 587–596. Duncan, M., Clarke, N., Birch, S., Tallis, J., Hankey, J., Bryant, E.,  & Eyre, E. (2014). The efect of green exercise on blood pressure, heart rate and mood state in primary school children. International Journal of Environmental Research and Public Health, 11(4), 3678–3688. Gill, T. (2014). The benefts of children’s engagement with nature: A systemic literature review. Children Youth and Environments, 24(2), 10–34. Harper, N., Rose, K., & Segal, D. (2019). Nature-based therapy: A practitioner’s guide to working outdoors with children, youth, and families. New Society Publishers. Jordan, M., & Hinds, J. (2016). Ecotherapy: Theory, research and practice (1st ed.). Red Globe Press. Kaussner, Y., Kuraszkiewicz, A., Schoch, S., Marke, P., Hofmann, S., Baur-Streubel, R., Kenntner-Mabiala, R.,  & Pauli, P. (2020). Treating patients with driving phobia by virtual reality  exposure therapy—A pilot study.  PLoS One, 15(1), Article e0226937. Kirsh, S. (2010). Media and youth: A developmental perspective. Wiley-Blackwell. Louv, R. (2019). Last child in the woods: Saving our children from nature-defcit disorder. Algonquin Books. Mygind, L., Kjeldsted, E., Hartmeyer, R., Mygind, E., Bølling, M., & Bentsen, P. (2019). Mental,  physical and social health benefts of immersive nature-experience for children and adolescents: A systematic review and quality assessment of the evidence. Health & Place, 58, Article 102136. Ophir, Y., Rosenberg, H., & Tikochinski, R. (2021). What are the psychological impacts of children’s  screen use? A  critical review and meta-analysis of the literature underlying the world health organization guidelines.  Computers in Human Behavior, 124, Article 106925. Ratey, J., & Loehr, J. (2011). The positive impact of physical activity on cognition during adulthood: A review of underlying mechanisms, evidence and recommendations. Reviews in the Neurosciences, 22(2), 171–185. Rosenblatt, L., Gorantla, S., Torres, J., Yarmush, R., Rao, S., Park, E., Denninger, J., Benson, H., Fricchione, G., Bernstein, B., & Levine, J. (2011). Relaxation response—based yoga improves functioning in young children with autism: A  pilot study.  The Journal of Alternative and Complementary Medicine, 17(11), 1029–1035.

Avoiding Nature Deficit Disorder

147

Samani, A.,  & Heath, M. (2018). Executive-related oculomotor control is improved following a 10-min single-bout of aerobic exercise: Evidence from the antisaccade task. Neuropsychologia, 108, 73–81. Wells, N., & Evans, G. (2003). Nearby nature: A bufer of life stress among rural children. Environment and Behavior, 35(3), 311–330. Williams, F. (2018). The nature fx: Why nature makes us happier, healthier, and more creative. W. W. Norton & Company.

Part Two

Video Game Directory With Ideas for Use in Psychotherapy

Welcome to Part 2. I hope you fnd it useful. Here you will fnd a variety of video game titles (42 in total), organized alphabetically, with specifc ideas for how to use them in psychotherapy with young people, courtesy of the many interns and clients who contributed to this efort. There are many potential ways to use this part of the book, but the straightforward way is to ask your client what game she/he most enjoys playing and look for it alphabetically in the game directory. All the suggestions and ideas provided in these pages were developed using concepts from cognitive behavior therapy (CBT), narrative therapy, mindfulness, and values clarifcation. Because values clarifcation was only discussed briefy earlier in the book, an overview is provided next.

Values Clarification Strategies called “unfnished sentences” are included for each video game covered in this directory. Unfnished sentences are a simple approach in values clarifcation, an approach to counseling that endeavors to increase awareness of any values that may have a bearing on lifestyle decisions and actions. Values clarifcation can help young people refect on personal dilemmas and empower them to make decisions that are true to their identities. For this video game directory, clients’ answers to unfnished sentences provide a springboard to “think about thinking” and open space for alternative ways of thinking and behaving. Once realized, these alternative ways of thinking and behaving can be explored in more depth using the therapeutic questions and activities provided for each video game. Values clarifcation techniques tend to be an excellent approach in groups (e.g., Kirven & Edwards, 2019; Gunawan et al., 2019; Kirschenbaum, 2013) but can also be useful in individual psychotherapy. They integrate well with mindfulness, CBT, and other techniques for anxiety (e.g., Berghof et  al., 2018) and can shed light on client preferences, even when examined through the lens of video games. Practitioners using this book are encouraged to come up with their own unfnished sentences in addition to those provided. DOI: 10.4324/9781003222132-12

150

Video Game Directory

Process Used to Select the Games This directory was made possible through the tireless eforts of a few “expert consultants” and graduate-level interns. All the games selected have been used in practice as described. The process used for selecting the video games involved weekly meetings for over a year to learn from young people about their favorite games. Graduate-level interns collected this information, brainstormed ideas, and refned them in supervision. The video games that made it into the directory were distilled from over 100 options. Inclusion in the directory required the unanimous agreement of the young people informing the project after the unfnished sentences, questions, and activities were fnalized. Possible diagnoses to consider when using the games in this directory are provided, but by no means represent a comprehensive list. Mental health providers are encouraged to use the ideas, or a modifed version of them, with the client/patient population with whom they have the most expertise.

Understanding Video Game Ratings Entertainment Software Review Board (ESRB) ratings provide information about what is in a game so parents and consumers can make informed choices about which games are right for them. Ratings have three parts: Rating categories, content descriptors, and interactive elements. Rating categories for video games are: 1) E (Everyone), 2) E10+ (Everyone 10+), 3) T (Teen), M (Mature 17+), A (Adults Only 18+), and RP (Rating Pending). Content descriptors indicate content that may have triggered a particular rating and/or may be of interest or concern (e.g., substances, violence, blood/gore, language, nudity, humor, gambling, sexuality). Interactive elements highlight video game features that may be of interest or concern but do not infuence the rating assignment (e.g., users interact, in-game purchases). Most video games covered in this directory are rated E or E10+, with some exceptions for teens (e.g., Call of Duty). Every efort was made to include games that have minimal violence and high levels of customization. In most cases, the purpose for considering a game in the frst place was infuenced by its previous use in either individual psychotherapy or gamer group.

More Ways to Use This Game Directory This is certainly not a comprehensive list of games that could be used in psychotherapy with young people. Practitioners are encouraged to work collaboratively with their clients to consider other games that could be added. When in doubt, hand this book to your clients and ask them to

Video Game Directory

151

look through it and fnd a game that resonates with them. The video games in this directory can also be assigned as homework for clients who are willing to consider their responses to the unfnished sentences and questions outside of psychotherapy. If you are just beginning your journey of using video games in psychotherapy with young people, you could use this directory to help inform the games you choose to purchase for the ofce. You could also use the template provided in the appendix of this book to create new ideas for using video games in psychotherapy that may not be included on this list. A full list of the games covered in the current edition of Video Games in Psychotherapy is provided next. Among Us Angry Birds Animal Crossing: New Horizons Astroneer Bloons Tower Defense Call of Duty Crash Bandicoot 4: It’s About Time Civilization VI Cozy Grove FIFA Fortnite Fruit Ninja Just Dance 2021 League of Legends Lego series Madden Mario Kart Minecraft NBA 2k20 New Super Lucky’s Tale Ōkami Overcooked Pac-Man Pokémon: Brilliant Diamond Portal 2 Raft Ratchet & Clank: Rift Apart Rock Band Rocket League Sea of Thieves Spiritfarer Star Wars: The Old Republic Stardew Valley

152

Video Game Directory

Super Mario Bros. Super Mario Galaxy Super Mario Party Super Mario Sunshine Super Smash Bros. Terraria The Artful Escape The Legend of Zelda: Breath of the Wild The Sims

References Berghof, C., Forsyth, J., Ritzert, T., Eifert, G., & Anderson, D. (2018). Evaluation of the contribution of values clarifcation to a brief mindfulness meditation intervention for anxiety. Journal of Clinical Psychology, 74(9), 1387–1402. Gunawan, I., Wibowo, M., Purwanto, E., & Sunawan, S. (2019). Group counseling of values clarifcation to increase middle school students’ empathy. Psicología Educativa, 25(2), 169–174. Kirschenbaum, H. (2013). Values clarifcation in counseling and psychotherapy: Practical strategies for individual and group settings. Oxford University Press. Kirven, J., & Edwards, A. (2019). Adolescents values clarifcation and development: A model for group counseling. Child & Youth Services, 40(1), 4–22.

Video Game Directory

153

Video Games in Psychotherapy Directory Among Us Available on iOS, Android, PC, and Mac Rated E10+ for Everyone 10+ Developers: InnerSloth, LLC Possible Diagnoses: Social anxiety, autism, ADHD Themes: Focus, teamwork, skill building Among Us is a multiplayer strategy game where players need to fgure out who the imposter is before they kill all their teammates. As a crew member, the player completes mini tasks as fast as possible while staying alert and narrowing down players until the imposter is found. When in the imposter role, players try to knock of as many crew mates as possible without being caught. Whoever completes their task frst wins!

Why Use This Game in Therapy With Young People • • •

Many opportunities to work on teamwork/socialization skills Many opportunities to externalize the problem Great for many ages and skill levels

Unfinished Sentences • • • •

I can work together with my crewmates by_______. I can focus on my tasks by________. My favorite part of the game is _______ because________. I like/dislike being the imposter because________.

Therapeutic Questions • •

•

What skills do you need to be successful in this game? Did you possess these skills before you started playing, or did you develop them? If you developed them, how did you do that? What is the best way to maneuver through the game and be successful? Do you like to map out how you are going to complete tasks, or just run around and see what others are doing? Why do you think you prefer to do it this way? Have you ever tried to play the game in a completely diferent way? Did you ever have to work together with your team to defeat the imposter? What was it like? How did you communicate with your teammates? Did anyone ever doubt you or think you were the imposter?

154

•

Video Game Directory

When you are the imposter, people are against you. This can be a stressful part of the game. In real life when people are against you, how do you deal with it?

Ideas for Therapeutic Activities • • •

Have your client create an Among Us map that represents his/her own journey. Talk to your client about how to maneuver the map to be successful. Create an Among Us map where the problem is the imposter. Work together with the client to defeat the imposter. Relate this back to real life. Create an Among Us map and scavenger hunt with tasks (e.g., breathing, assertiveness) that help your client solve a problem (e.g., bullying, test anxiety, social stressors).

Angry Birds Available on mobile devices Rated E for Everyone Developers: Rovio Entertainment Possible Diagnoses: ADHD, autism, anxiety Themes: Focus, strategy, overcoming obstacles Angry Birds is a mobile puzzle game where the player uses a slingshot to launch birds at pigs. The object of the game is to destroy the pigs so the birds can get back their eggs. Objects like TNT, crates, and rocks are often obstructing the pigs. Power-ups allow players to do things like make earthquakes or make their bird larger. Levels are won by destroying all the pigs and rescuing all the eggs.

Why Use This Game in Therapy With Young People • • •

Metaphors to represent strengths, goals, and constraints to achieving those goals Easy and fun for many ages and abilities Break down big goals into smaller ones

Unfinished Sentences • • •

If my (strength) was a power-up in Angry Birds it would be _______. Angry Birds is like my life because _______. My strategy for playing Angry Birds is _______ because _______.

Video Game Directory

155

Therapeutic Questions •

•

•

Have you ever needed to aim your last move perfectly to win the level? How did you fgure out where to aim? Can you think of a time in your real life when you needed to do something just right to achieve your goal? Have you ever needed to use a power-up so you could rescue the fnal egg? What power-up did you fnd most powerful? How did you know that it was the perfect power-up to use for your situation? Have you ever lost a level because you ran out of birds? What did you do?

Ideas for Therapeutic Activities •

•

Have your clients play a harder level on Angry Birds. Discuss how they should consider aiming for a smaller area rather than a bigger one. Discuss how breaking down goals may help them achieve a big goal in real life. Create an Angry Birds game to represent the client’s story. Power-ups can be used to represent strengths, eggs can be used to represent goals, pigs can be used to represent problems, and obstacles to hitting the pigs can be used to represent constraints to overcoming the problem.

Animal Crossing: New Horizons Available on Nintendo Switch Rated E for Everyone Developers: Nintendo Possible Diagnoses: Autism, anxiety, OCD, depression Themes: Socialization, individuality, stress reduction In Animal Crossing: New Horizons, players and their villager friends create the island of their dreams. Through fshing, bug catching, and digging, players can gather materials to sell or donate to the museum. Players can customize their island to promote interaction with villager friends. Do not forget to buy some turnips on Sunday mornings!

Why Use This Game in Therapy With Young People • •

Express individuality through multiple options for customization No violence, making it appropriate for all ages and developmental levels

156

• •

Video Game Directory

It can be a fun and unique way to relax It is fun for all ages and abilities

Unfinished Sentences • • • •

The villager I am most like is _______ because_______. I can create my perfect happy place in the game by_______. If I could go to anyone’s island it would be _______ because_______. If there is one thing I could learn from my villagers about being a good friend it would be_______.

Therapeutic Questions •

• • • •

How did you create a happy place for yourself? What does it feel like to go there? How do you know when you need to go there? Could you imagine this place even when you are not playing Animal Crossing? What type of villagers do you like making friends with? How come? What stands out to you the most about these villagers? What does your routine in Animal Crossing say about who you are? What do you think your friends’ islands might look like? Family members? How does your player style for Animal Crossing compare with your real-life priorities?

Ideas for Therapeutic Activities • • •

Have the client create a happy place in the game that can be used as an image when practicing self-regulation skills. Have the client plan an event in the game and discuss how decisions were made to do this. Use Animal Crossing as part of a routine to assist with psychophysiological self-regulation.

Astroneer Available on PC and Mac Rated E for Everyone Developers: System Era Softworks Possible Diagnoses: Anxiety, depression, OCD Themes: Creativity, socialization Astroneer is a crafting and exploration game where the player tries to expand and develop his/her base on alien worlds. Through crafting,

Video Game Directory

157

mining, traveling, and exploring, players can create their own base. Play independently or with friends to advance through the game.

Why Use This Game in Therapy With Young People • • •

Great metaphors to represent problems Provides opportunities to externalize the problem Opportunities for reauthoring and discussing future focus

Unfinished Sentences • • • •

My favorite planet is _______. My favorite thing to craft in Astroneer is _______. I get resources to explore planets by _______. I make sure I always have oxygen by _______.

Therapeutic Questions • • •

When you land in Astroneer, you must expand your base by fnding resources. What resources do you like to fnd frst? How come? How did you learn that this is the resource you want to prioritize? How does it feel when you are not connected to the tether? What do you do to get back to the tether? What do you do to prevent being disconnected from the tether in the frst place? What is your tether in real life? What resources would you need if you were a planet? How come?

Ideas for Therapeutic Activities •

In Astroneer, you can create your own rover with its own special features. Have your client create a rover that includes his/her strengths and skills for overcoming the problem.

Bloons Tower Defense Available on PC and Mac Rated E for Everyone Developers: Ninja Kiwi Possible Diagnoses: ADHD, anxiety, depression Themes: Focus, strategy, skill building, problem solving Stop any bloons from escaping the maze by building and upgrading bloons and popping towers. Towers can throw darts, tacks, bombs, and ice. Bloons Tower Defense (also known as Bloons TD) is a series of tower defense games created and produced by Ninja Kiwi.

158

Video Game Directory

Why Use This Game in Therapy With Young People • • • •

Many opportunities for externalization Limited violence, making it suitable for all ages Great metaphors representing constraints to the problem Consider strategies for defending against the problem

Unfinished Sentences • • • •

My strategy for blocking the end of the track is______ because______. My favorite tower is _______ because_________. I start most levels by _______ because________. I would describe my strategy in this game as __________.

Therapeutic Questions • • • •

What could a tower represent in your life? What strategies do you use to block negative infuences in your life? How do you cope with/overcome hard levels in the game and the emotions that come with them? Can you use some of these strategies in your real life? What other skills do you develop playing this game, and how can you apply them in your real life?

Ideas for Therapeutic Activities • •

Challenge the client to improve her/his high score from session to session. Examine the process for improvement. Ask: Did you have to change your strategy, or did you simply get better at your previous strategy? Both? Help your client create a plan to block the negative infuences on his/ her life using some of the strategies used in Bloons Tower Defense.

Call of Duty Available on Xbox, PlayStation, Nintendo systems Rated M for Mature Developers: Multiple Possible Diagnoses: Autism, ADHD, anxiety Themes: Teamwork, focus, strategy Call of Duty is a frst-person shooter game where the player is in the middle of a warzone. With many diferent weapons to choose from, the player’s goal is to travel the map and fnd enemies. The game is won when all the enemies have been defeated. There are many diferent maps in this

Video Game Directory

159

game, so the terrain is always changing. This game can be played alone, in co-op mode, or multiplayer.

Why Use This Game in Therapy With Young People • • •

Many opportunities to externalize the problem Good metaphors for discussing strategy and breaking down goals Despite the violence, it is widely played and enjoyed by millions of young people, so it is familiar to most

Unfinished Sentences • • • • • •

My favorite hero in Call of Duty is_______. Some strengths of (my favorite hero in Call of Duty) that I have are _______. My best defense in life is _______. My favorite weapon in Call of Duty is _______ because _______. My favorite map in Call of Duty is _______ because _______. My strategy when playing Call of Duty is _______.

Therapeutic Questions • • • •

In Call of Duty, have you ever had to learn about your enemy? What did you learn? How did you use the information? How is does your strategy in Call of Duty compare with how you deal with problems in real life? In Call of Duty, have you ever had to play against a more advanced player? What was that like? Did you win or lose? Did you learn anything from this experience? In Call of Duty, violence is used to solve problems. What do you think of this?

Ideas for Therapeutic Activities •

Set up a map with your client with enemies that must be defeated along the way. Consider a strategy to defeat these enemies. What strengths or skills will your client need? What happens when the map has been conquered?

Crash Bandicoot 4: It’s About Time Available on PlayStation 4  & 5, Xbox series, Nintendo Switch, and Microsoft Windows Rated E10+ for Everyone 10+

160

Video Game Directory

Developers: Naughty Dog Possible Diagnoses: Autism, ADHD, anxiety Themes: Focus, strategy, overcoming obstacles Crash Bandicoot 4: It’s About Time begins with two evil masterminds who want to take over the universe escaping from their prison and leaving a massive hole in the atmosphere. Players play as Crash Bandicoot as he travels through diferent interdimensional quests. Crash is constantly battling and maneuvering diferent obstacles by wall running, rope swinging, and zip-lining. Players can complete quests and collect gems to unlock unique skins to customize Crash or his pal Coco. Each major challenge grants Crash and Coco diferent skills to use (e.g., stretching time). The game can be played as either Crash or Coco, and there are several other characters that can be controlled in the game to ofer different perspectives. Players can revisit levels to see what new experience they might encounter.

Why Use This Game in Therapy With Young People • • •

Great opportunities to externalize the problem Excellent array of therapeutic metaphors Provides opportunities to examine problem-solving skills

Unfinished Questions • • •

My favorite character to play as is _______. My least favorite level to play is _______. My strategy for playing Crash Bandicoot 4 is _______.

Therapeutic Questions • • • •

When do you choose to go back and replay a level? How come? When do you avoid replaying levels? How come? What does this mean about what you don’t like in real life? Have you ever been stuck on a level and fnally completed it? How did it feel when you accomplished the level? What is your least favorite object/creature to face in Crash Bandicoot 4? How come?

Ideas for Therapeutic Activities •

Create a level of Crash Bandicoot with your client. Include a goal at the fnish line. Identify what challenges your client may face along

Video Game Directory

161

the way and place “power-ups” (i.e., skills and strengths) strategically within the level to combat these challenges. Civilization VI Available on PC and Mac Rated E10+ for Everyone 10+ Developers: Aspyr and Firaxcis Games Possible Diagnoses: ADHD, autism, anxiety Themes: Strategy, focus, socialization Civilization VI is a grand strategy game where the player controls her/ his own nation. Players choose starting characters and guide warriors, builders, settlers, etc. through expanding and exploring a new civilization. Through research, players can advance through diferent eras and create new technologies. There are many diferent maps and ways to play or win.

Why Use This Game in Therapy With Young People • • •

Promotes discussions around strategy Many metaphors to represent constraints to the problem Practice social skills and cooperation in multiplayer mode

Unfinished Sentences • • • •

Something I had to research in my own life was _______. The barbarians in my real life are _______. One of my alliances in my real life is _______. I will become the leader of my personal world when I _______.

Therapeutic Questions • • •

Which wonder of the world do you like the best and why? What might this say about you? What tree is your favorite (tradition, honor, exploration, etc.) and why? Did this tree give you specifc traits to boost your game? Why did you need those traits? How did you know you needed that trait? In Civilization VI there are many opportunities to form alliances. Have you ever had to form an alliance? How come? What were the advantages and disadvantages to this alliance? Could there be advantages and disadvantages to forming an alliance with the problem? What could those be?

162

Video Game Directory

Ideas for Therapeutic Activities • •

Have your client build his/her own wonder of the world. Discuss the meaning behind the client’s decisions. Have your client create a tree flled with traits needed to defeat the problem.

Cozy Grove Available on PC, Mac, PlayStation, Xbox, Nintendo Switch, iOS Rated E for Everyone Developers: Spry Fox Possible Diagnoses: Depression, anxiety, OCD Themes: Patience, perseverance, therapy as a journey Cozy Grove is a life-sim game where the player (a spirit scout) goes camping on a haunted island. The player’s job as a spirit scout is to help the bears rediscover their lost memories. Players meet many diferent bears along the way, who all possess many diferent memories. This game is a relaxing game with the ability to fsh, explore, and scavenge for things on the island.

Why Use This Game in Therapy With Young People • • • • •

Large supply of metaphors Multiple options for customization No violence, making it appropriate for all ages and preferences A diferent way to relax It is fun for all ages and abilities

Unfinished Sentences • • •

My favorite bear is _______ because _______. My favorite/least favorite thing to do in Cozy Grove is _______. Every time I log in I make sure to _______.

Therapeutic Questions • •

What bear do you most resemble from Cozy Grove? In what ways? How do you feel about this bear? There are many diferent tasks to do in Cozy Grove. Which task is your favorite? Why is this task your favorite? What do you think this says about you?

Video Game Directory

• •

163

The overall task of Cozy Grove is to help all the bears discover their memories. What are some of your favorite memories? Communicating with bears is easier/harder than communicating with some people. How come?

Ideas for Therapeutic Activities •

Create an island with many diferent bears to help. Each bear can have something specifc to work on (anger, anxiety, etc.). Have your client complete tasks that involve practicing skills learned in therapy and teach the bear how to do these tasks.

FIFA Available on PC, Mac, PlayStation, Xbox Rated E for Everyone Developers: EA Sports Possible Diagnoses: Anxiety, autism, ADHD, depression Themes: Teamwork, focus, socialization, strategy FIFA is a simulation game where players can select players from real-life professional soccer teams, practice their skills, and play in custom matchups. FIFA includes a variety of game modes that allow players to practice many diferent skills and play through them virtually. This game can be played independently against the computer or with friends.

Why Use This Game in Therapy With Young People • • •

Popular game with teens that provides numerous customization options Teams and matchups can have great meaning and promote both deconstruction and reauthoring Skills practice functions correlate well with practicing skills in therapy

Unfinished Sentences • • • • •

My favorite team to play in FIFA is _______. My least favorite team in FIFA is _______. The skill I most value in FIFA is _______. The soccer player in FIFA who I am most like is _______. The team in FIFA that best represents (the problem) is _______.

164

Video Game Directory

Therapeutic Questions • • •

What is your favorite thing about playing FIFA? How come? What do you think this says about you? Do you think others feel that way about that part of the game? How do you know what skill to use in FIFA? Is it easy to fgure out in that moment? What makes it so easy? Team play is very important in FIFA to score a goal. How did you learn about your teammates’ strengths and limitations? What is the ideal balance of strengths and limitations in FIFA?

Ideas for Therapeutic Activities •

•

Imagine a new skill with your client for use in FIFA. Consider what makes this a useful skill. Discuss when this skill would be most efective with your client and set the stage to design additional skills to be used in diferent situations. Create custom teams with the client representing both the client’s strengths and the problem. Allow your client to pick diferent strengths and weaknesses for each player. Process decisions made and consider their meaning. Pit the teams against each other, with your client playing the role of the strengths-based team.

Fortnite Available on PC, Mac, Xbox, PlayStation, and Nintendo Switch Rated T for Teen Developers: Epic Games and People Can Fly Possible Diagnoses: Anxiety, OCD, depression, autism Themes: Teamwork, focus, skill building, resourcefulness Fortnite is an action game where players run around a map that is constantly shrinking. Players must stay within the shrinking circle to ensure safety. Along the way players collect resources (e.g., bandages, wood, guns, etc.) and defeat other players to give them the best chance at winning the game. Players are also able to use the resources they pick up to build forts and heal themselves. Be the last person or team standing to win.

Why Use This Game in Therapy With Young People • • • •

Large selection of metaphors that could represent strengths or constraints/problems Promotes problem-solving Requires strategy and defensive approach to be successful Violence is minimally graphic

Video Game Directory

•

165

One of the most popular games for young teenagers. It is a hard game to avoid talking about with young gamers.

Unfinished Sentences • • • •

If (the problem) was an enemy in Fortnite it would be _______. I feel safest in Fortnite when I _______. My favorite resource in Fortnite is _______ because _______. My favorite skin in Fortnite is _______.

Therapeutic Questions •

• •

Have you ever had to gather resources to protect yourself in Fortnite? How did you do it? What resources did you need and how did you decide that? Can you think of a similar time in your real life? Have you ever achieved a victory royale? How did you do that? Which of your strengths helped you to achieve that? If you could have any skin in Fortnite in your real life, what would it be and how come?

Ideas for Therapeutic Activities •

•

Compare gathering resources in Fortnite with gathering resources in real life. What does your client need to get through a day at school? To deal with the problem? When does the client feel safest and how come? Set up a map of Fortnite with the client. Have diferent characters along the way that represent constraints to the future focus. Discuss which tools would be needed to defeat each character.

Fruit Ninja Available on mobile devices, Windows PC, VR Rated E for Everyone Developers: Halfbrick Studios Possible Diagnoses: ADHD, autism, anxiety Themes: Focus, strategy, movement Fruit Ninja is a casual mobile game where fruit fies up in the air and the player has to slice it in half. Players use their fnger to swipe across the screen, causing a blade to slice the fruit. Players must also avoid bombs and fying items that are not fruit. Slice one and the game is over. Points are earned for successful fruits sliced.

166

Video Game Directory

Why Use This Game in Therapy With Young People • • •

Easy and fun for many ages and abilities A great game to build focus and process a client’s strategy for maintaining attention Super satisfying feel and sounds when successful!

Unfinished Sentences • • • •

The bombs in my life are _______. I can avoid them by _______. My favorite blade is _______ because _______. I am able to stay focused and aware of the fying items in Fruit Ninja by _______.

Therapeutic Questions • • • •

In Fruit Ninja, if you accidentally hit the bomb it explodes. Tell me about a time when you accidentally focused on the wrong thing. What was it like? Did you learn anything from this experience? Discuss how the risk of explosions is part of what makes Fruit Ninja fun. What would it be like if there were no bombs in your life? Would it have the same meaning? When are you best at playing Fruit Ninja? How come? What do you think this means? What role (if any) does anxiety play when you are playing Fruit Ninja?

Ideas for Therapeutic Activities • •

Create a version of Fruit Ninja with your client where the fruits are goals, the bombs are obstacles, and the blades are strengths. Use Fruit Ninja VR to practice skills related to maintaining focus, mindfulness, and/or promote movement.

Just Dance 2021 Available on Nintendo Switch, PlayStation 4 and 5, Xbox Rated E10+ for Everyone 10+ Developers: Ubisoft Possible Diagnoses: Autism, OCD, depression, anxiety Themes: Movement, perseverance, focus, socialization

Video Game Directory

167

Just Dance 2021 is a movement-based dance game where players mimic moves on the screen and dance to popular music to earn points. Players can play individually or with up to six others. Dancers also have the freedom to create their own playlist of songs and dances that they like. The base game features ten kid-friendly songs for those younger than the maturity rating. Just Dance 2021 players can choose the character they want to dance with, adding even more customizability.

Why Use This Game in Therapy With Young People • • • •

Easy and fun for many ages and abilities Great game to build focus and process problem-solving skills Can be used in individual or group therapy Includes the additional benefts of movement and music

Unfinished Sentences • • • • •

My favorite dance is _______. My favorite song to dance to is _______. My favorite character to dance with is _______. One thing that I like about Just Dance 2021 is _______. One thing that I do not like about Just Dance 2021 is _______.

Therapeutic Questions • • •

Do you prefer to dance individually or with others? What do you think this means about you, if anything? Have you ever been stuck on a dance and then finally received the score you wanted? What did that feel like for you? How did you do it? How does it feel to dance to songs you normally would not choose? Are you able to make it fun and get into the dance anyway? If so, how?

Ideas for Therapeutic Activities • •

Play the game with your client/clients in group or individual sessions! Pay attention to client mood, song, and dance selections. Use Just Dance 2021 to help clients express their feelings by selecting songs and dances that ft with how they feel now or during a time being processed in therapy.

168

Video Game Directory

League of Legends Available on PC and Mac Rated T for Teen Developers: Riot Games Possible Diagnoses: Autism, ADHD, social anxiety Themes: Teamwork, socialization, reauthoring League of Legends is a multiplayer online battle arena (MOBA, a realtime strategy sub-genre) where two teams of players battle using characters called “champions.” Victory is achieved by conquering the enemy (Nexus) and other structures and non-player “minions.” There are different roles each champion can take and strategies that can be used that are not necessarily defned in the game but have developed around how people typically play it.

Why Use This Game in Therapy With Young People • • • •

MMO format provides some opportunities to practice social skills and build community of support Great metaphors representing constraints to problems Many opportunities to externalize problems Champions are great metaphors for strengths and preferred self

Unfinished Sentences • • • • •

I think ________ is the strongest champion because_______. Some of the strengths of (champion from previous sentence) that I exhibit are_______. My favorite champion archetype (support, tank, etc.) is _______ because_______. I use champions in the _______ archetype(s) because_______. I play _______ mode most often because_______.

Therapeutic Questions • • •

What do you look for in a champion besides the archetype? Do their stories or design speak to you? Do you enjoy working with others on a team when playing League of Legends? What are the benefts of working together as a team? Would you sometimes prefer to work alone? How come? When do you most enjoy playing on a team vs. alone? What do you think contributes to this? The players on the team? How the game is going? How your day is going?

Video Game Directory

•

169

What are some of the ways you interact with your team? What is your role? Are you more of a leader or support player when you play League of Legends on a team? How do you communicate with your teammates? How did you learn this way of communicating?

Ideas for Therapeutic Activities •

• •

Take some of the productive ways you interact with your team(s) online and set a mission to apply them to real life. Consider some of your answers to the last therapy question, but also consider more specifc things, like being casual vs. formal and polite vs. familiar. Consider “trying on new archetypes” in real-life. Create an original champion for League of Legends based on the client’s strengths.

Lego Series Available on all consoles, PC, and Mac Rated E10+ for Everyone 10+ (varies based on Lego series) Possible Diagnoses: Anxiety, depression, OCD, autism Themes: Confdence, strategy, skill building The Lego series are adventure games where players take on the role of diferent characters (Harry Potter, Batman, Star Wars, etc.). Throughout the game players complete tasks and work through challenges to try to defeat whatever is in their way. All the Lego series video games are built on a collaborative platform that allows multiple players to work together to achieve the goals of the game. These are defnitely some of our favorite games for therapy.

Why Use This Game in Therapy With Young People • • • • • •

Excellent game for groups because of the collaborative gameplay Excellent game for building rapport with clients, also because of collaborative gameplay Many opportunities for externalizing the problem Many opportunities to work on teamwork/social skills Easy to play Many opportunities to work on problem-solving skills

Unfinished Sentences • •

My favorite cutscene/moment is______ because_______. I prefer playing through levels in ______ mode because_______.

170

• •

Video Game Directory

My favorite character is ______ because_______. The part of playing Lego games that I am best at is _______.

Therapeutic Questions • • • •

Have you ever needed to build a tool (or learn a new skill) to overcome a challenge? How did you do it? Have you ever needed to work at a problem for a long time? How did you get through it? What did you learn? Do you like collecting things like mini-kits and money in the game, or do you only do it when needed? Do you feel the same way about anything in your real life? What is the hardest thing about relying on other players to win the game? How come?

Ideas for Therapeutic Activities • •

Imagine with your client that her/his life is a Lego video game. Build a tool out of actual Legos that could be used against the problem in the Lego video game about your client’s life. Create a cutscene for a Lego game based on something your client is working on in therapy. Lego cutscenes tend to be humorous while still conveying serious events.

Madden Available on PlayStation and Xbox Rated E for Everyone Developers: EA Sports Possible Diagnoses: Anxiety, autism, ADHD, depression Themes: Teamwork, focus, socialization, strategy Madden is a simulation game where players can select players from real football games and play as their dream team. Players can get creative with their plays and improve on their skills as they continue to play. This game can be played independently against the computer or with friends.

Why Use This Game in Therapy With Young People • •

Popular game with teens that provides numerous customization options Teams and matchups can have great meaning and promote both deconstruction and reauthoring

Video Game Directory

171

Unfinished Sentences • • • • •

My favorite team to play in Madden is _______. My least favorite team in Madden is _______. My favorite ofensive play in Madden is _______. The football player in Madden who I am most like is _______. The team in Madden that best represents (the problem) is _______.

Therapeutic Questions • • •

What is your typical strategy when playing Madden? What do you think this says about you, if anything? How do you decide what play to choose? How is this the same or different from how you make decisions in real life? What makes a good team in Madden? How come? How about in real life?

Ideas for Therapeutic Activities •

•

Create a play against the problem. How would you “draw it up”? Discuss when this play would be most efective with your client and set the stage to design additional plays to be used in diferent situations. Create custom teams with the client representing both the client’s strengths and the problem. Allow your client to pick diferent strengths and weaknesses for each player. Process decisions made and consider their meaning. Pit the teams against each other, with your client playing the role of the strengths-based team.

Mario Kart Available on Nintendo systems Rated E for Everyone Developers: Nintendo Possible Diagnoses: Autism, ADHD, anxiety, depression Themes: Teamwork, overcoming obstacles Mario Kart is a racing party game where the player races against the computer (or friends) to the fnish line. Along the way, players can pick up coins to make their cars go faster or things to throw at the cars in front of or behind them to get ahead. Win as many races as you can to claim the trophy!

172

Video Game Directory

Why Use This Game in Therapy With Young People • • •

Minimal violence, making it appropriate for most ages and preferences Many opportunities to work on socialization/teamwork skills A game that is perfect for all ages and abilities; it is always a favorite because it is fun and easy to play

Unfinished Sentences • • • • • •

If my (problem) was a shell or other object in Mario Kart it would be _____ because _____. If I could take a shortcut in my real life it would be ________. My favorite character in Mario Kart is _______. My favorite item in Mario Kart is _______. My least favorite item in Mario Kart is _______. My favorite car option in Mario Kart is______.

Therapeutic Questions • • • •

What obstacles have you overcome in your life? How did you do it? What’s your favorite course to play? What does this say about you? What’s more important to you, winning or having fun? In what areas is it the same for you in real life? What areas are diferent? How does it make you feel when you are hit by a blue shell, or something else that you can’t avoid when you are in the lead? Would you want to remove these objects from the game? Why or why not?

Ideas for Therapeutic Activities • • •

Choose a car and character to represents your clients’ strengths. Have your client design a Mario Kart course that represents her/his own journey. Where are the obstacles? When is the fnish line and what does it look like? Have your clients play time attack stages and improve their time. How did they improve? Ask them how improving or hitting a setback made them feel. Ask your clients about what they learned from this experience that could inform their real lives.

Minecraft Available on all consoles, PC and Mac Rated E10+ for Everyone 10+ Developers: Mojang Studios Possible Diagnoses: Anxiety, autism, depression, ADHD Themes: Creativity, assertiveness, socialization, individuality

Video Game Directory

173

Minecraft is an open world/sandbox-style survival and crafting game. You can build a world to your liking individually or with friends. Along the way, there will be chances to defeat zombies, slimes, skeletons, and creepers. It is the player’s role to gather resources, build things (e.g., shelter), and stay safe from the monsters.

Why Use This Game in Therapy With Young People • • • •

Great metaphors representing constraints to the problem Many opportunities to externalize the problem Express individuality through multiple options for customization Extremely popular, It is not possible to work with young gamers without spending some time talking about Minecraft.

Unfinished Sentences • • •

I can defeat mobs by_______. I can create a safe space in Minecraft by_______. ______ is my favorite biome in Minecraft because_______.

Therapeutic Questions • • • • • •

If your problem was a mob, what would it be? What mob is easiest for you to defeat? How come? Do you have a strategy that makes it easier? Is this a strategy you can use in other areas of your life? What mob is hardest for you to defeat? How come? Is there anything you can do to make it easier to defeat? How did you learn to defeat other mobs? What is your favorite thing to build in Minecraft? How come? What do you think this says about you? What is your favorite material to build with in Minecraft? How come? What do you think this says about you? What is your least favorite thing to build in Minecraft? How come?

Ideas for Therapeutic Activities • •

•

Have your client create a safe space in Minecraft. Discuss why this space feels safe to her/him. What can be replicated in the client’s real life? What is essential to this safe space? Build something in Minecraft with your client that represents different parts of the treatment plan. For example, your client can build diferent structures that represent goals and/or constraints to achieving those goals. Use Minecraft in groups! Give clients instructions to build something together!

174

Video Game Directory

Figure P2.1 T hese images were created in Minecraft by a nine-year-old girl with anxiety. The image on the left is the outside of her “safe space” and is filled with things she loves and finds beautiful (e.g., waterfall, flowers). The image on the right is the inside of this client’s safe space and can be entered by dropping through the small trap door visible above the waterfall on the image to the left. The client described this space as “relaxing and safe because no one can see me, and I  can’t see all of the beautiful things that make it hard for me to focus.”

NBA 2k20 Available on PlayStation and Xbox systems, Nintendo Switch, and Windows PC Rated E for Everyone Developers: Visual Concepts Possible Diagnoses: Autism, OCD, ADHD Themes: Socialization, problem solving, focus, teamwork NBA 2k20 is a basketball simulation game where players can mimic the teams played in the National Basketball Association (NBA). With many teams in the NBA to choose from, and a select few WNBA teams, players can control all the players on their team utilizing realistic ofensive and defensive strategies. As with a real basketball game, the team with the most points at the end of the four quarters wins the game.

Why Use This Game in Therapy With Young People • • • •

Minimal violence, making it suitable for most ages and preferences Promotes dialogue related to problem-solving Reinforces team-based approach to problem-solving Promotes dialogue related to communication skills

Video Game Directory

175

Unfinished Sentences • • • •

My least favorite team in NBA 2k20 is _______. My favorite team in NBA 2k20 is _______. The basketball player in NBA 2k20 I’m most like is ______. The basketball player who I like the least is _______.

Therapeutic Questions • • •

How do you choose what play to use? What does your strategy in NBA 2k20 say about who you are and how you operate in your real life? What makes a good team in NBA 2k20? How come? Is there anything we can learn from this that could help in real life? How do you overcome playing against challenging players and teams? How does this compare with how you respond to challenges in your real life?

Ideas for Therapeutic Activities •

•

Have clients create one team based on their strengths and another team based on the problem. Have clients process how they came to their decisions. Consider what it would be like if these teams played each other. Create a play sheet to be used against the client’s real-life problem(s). Use ideas from NBA 2k20 to inform the plays.

New Super Lucky’s Tale Available on Nintendo Switch, Xbox, Microsoft Windows, and PlayStation 4 Rated E for Everyone Developers: Playful Studios Possible Diagnoses: Autism, ADHD, anxiety, depression Themes: Individuality, determination, strategy New Super Lucky’s Tale is a single-player, 3D platforming adventure game where players play as Lucky as he travels through a magical artifact, the Book of Ages. Along the way, Lucky meets new friends and worlds while recovering missing pages by collecting coins and overcoming obstacles. These pages have been dispersed through many worlds by an evil sorcerer, Jinx. Jinx is accompanied by his family, the dreaded Kitty Litter. During the adventure, players will discover tons of collectibles, come across many diferent characters, and receive a collection of costumes

176

Video Game Directory

to choose from. Players can also play various mini-games and complete puzzles within the game.

Why Use This Game in Therapy With Young People • • •

Easy and fun for many ages Great opportunities to externalize the problem Requires perseverance

Unfinished Sentences • • • • •

I am similar to Lucky when _______. My favorite/least favorite world in New Super Lucky’s Tale is _______. When I fnd missing pages I feel _______. The character in New Super Lucky’s Tale that reminds me most of myself is _______. My favorite character in New Super Lucky’s Tale is _______.

Therapeutic Questions • • •

What is your typical strategy when you play New Super Lucky’s Tale? How come? What obstacles have you overcome in your real life? What was your strategy? What do you think that says about you? When do you choose to explore content within the game that is not necessary to advance within the story line? When do you ignore side content within the game?

Ideas for Therapeutic Activities •

Have your client create a New Super Lucky’s Tale level on a piece of paper using real-life challenges the client is working on in therapy as inspiration.

Okami Available on PC, Mac, Nintendo, Xbox, PlayStation Rated T for Teen Developers: Capcom, Ready at Dawn, Clover Studio, and HexaDrive Possible Diagnoses: Autism, anxiety, depression Themes: Overcoming adversity, positive thinking, mindfulness Okami is an action-adventure game with a painting mechanic that utilizes motion control. Players are in the role of Amaterasu, the Japanese god

Video Game Directory

177

of the sun, who is depicted as a white wolf. As Amaterau, players work to bring light back to the world while vanquishing evil.

Why Use This Game in Therapy With Young People • •

Numerous opportunities to fnd metaphors representing both strengths and problems Relaxing gameplay with embedded mindfulness concepts

Unfinished Sentences • • • •

My favorite song in Okami plays when _______. The most beautiful part of Okami is _______. The part of Okami that left the greatest impression on me is _______. My favorite weapon type is _______ because _______.

Therapeutic Questions • •

When do you choose to explore content that is not necessary to advance the story? When do you ignore side content? How come? What do you think this may say about you and what is important to you? Sometimes in Okami you draw to activate abilities. Is there anything in life that you like doing diferently than others? How come?

Ideas for Therapeutic Activities • •

Draw the problem in the art style of Okami. Okami draws on the religion of Shintoism and Japanese folklore. Give your client a mission to research some of the stories from Shintoism and return with refections on those that resonated.

Overcooked Available on Nintendo Switch Rated E for Everyone Developers: Ghost Town Games Possible Diagnoses: Anxiety, depression, OCD, autism Themes: Problem solving, focus, strategy, cooperation, communication Overcooked is a cooking simulation game where players control a number of chefs in kitchens flled with a variety of hazards and obstacles. Gameplay requires players to work together to prepare meals to specifc orders under a time limit. Along with Portal 2, this is one of the best co-op games

178

Video Game Directory

for promoting efective communication and cooperation both in small groups and between client and therapist.

Why Use This Game in Therapy With Young People • • •

Fun for most ages and abilities True co-op gameplay One of the best games to use in small groups

Unfinished Sentences • • •

My favorite/least favorite thing to cook in Overcooked is _______. The strength that helps me the most when playing Overcooked is _______. My typical strategy when playing Overcooked is _______.

Therapeutic Questions • •

What role do you like to play when playing Overcooked? How come? What might this say about you and how you operate with others? What are some of the communication skills necessary to efectively beat levels in Overcooked? How do you think this compares to real life?

Ideas for Therapeutic Activities: •

• •

Design a level in Overcooked with your client that includes dishes representing the steps necessary to achieve a therapy goal. Process the role that the client would play in beating this level and what that means about the type of help/support he/she may require. Play Overcooked with your client! The game itself is designed in a way that promotes a collaborative partnership, one of the keys to efective psychotherapy with young people. Use Overcooked in a small group to promote cooperation and efective communication skills.

Pac-Man Available on Arcade, Nintendo systems, PC, Mac, PlayStation, Xbox Rated E for Everyone Developers: Namco, Atari Possible Diagnoses: ADHD, autism, anxiety Themes: Focus, strategy Pac-Man is a retro arcade game where Pac-Man roams through diferent levels eating dots and trying to avoid ghosts. Players move to new, faster

Video Game Directory

179

levels once they eat all the dots on the current screen. Once a player has made contact with three ghosts, the game is over. Gather some extra bonus points by eating some fruit along the way!

Why Use This Game in Therapy With Young People • • •

Many opportunities for metaphors that shed light on strengths and problems Easy for many ages and abilities Retro gaming is cool

Unfinished Sentences • • •

My strategy in Pac-Man is _______. I like retro gaming because _______. If I could turn my real-life problem invisible so it couldn’t hurt me I would _______.

Therapeutic Questions • • •

Have you ever felt like Pac-Man trying to get through a day? What were the ghosts in your life that day? What were the dots? Have you ever fnally made it past a level that you had been stuck on for a while? How did you do it? How did that feel? Have you ever been cornered by a bunch of ghosts in Pac-Man? What did you do? How about in real life?

Ideas for Therapeutic Activities •

Have your client create a Pac-Man level on paper with challenges along the way that are related to what is being worked on in therapy. For example, challenge a client to use breathing or grounding skills when they get to specifc points in the maze. Use ghosts to represent constraints to the client’s goals. Fruit can be used to represent strengths.

Pokémon Brilliant Diamond Available on Nintendo Switch Rated E for Everyone Developers: ILCA, Inc. Possible Diagnoses: Autism, depression, OCD, anxiety Themes: Socialization, strategy, perseverance Set in the Sinnoh region, a professor famous in the feld of Pokémon Evolution invites you to travel across the land to complete a Pokémon encyclopedic record referred to as Podex. After choosing a Pokémon

180

Video Game Directory

partner, players begin their journey across Sinnoh to complete the Podex. Along the way, players will come into contact and compete against the gym leaders, the strongest Pokémon trainers in each town. During the journey, players discover many legendary Pokémon while avoiding the members of Team Galactic.

Why Use This Game in Therapy With Young People • • •

Story deals with many themes that are likely to resonate with young people in therapy Excellent array of therapeutic metaphors Great opportunities to externalize the problem

Unfinished Sentences • • •

The Pokémon I am most like is _______. The gym leaders remind me of _______. My least favorite character in Pokémon Brilliant Dream is _______.

Therapeutic Questions: • • • •

How do you overcome challenges set by Team Galactic? How does that compare to how you overcome challenges in your real life? There are many diferent events to play in Pokémon Evolution. Which is your favorite to play? How come? What do you think this may say about you? How does communicating with the gym leaders compare to communicating with difcult people in real life? How come? Do you like collecting things like Pokémon or only when you need to? How come?

Ideas for Therapeutic Activities: • •

Imagine your client is in the game and create a personal Pokémon encyclopedic record of Pokémon that represent that clients’ strengths. Have your client make their own Pokémon cards to carry as reminders of how to overcome real-life challenges.

Portal 2 Available on Windows, Mac, PlayStation 3, and Xbox 360 Rated E10+ for Everyone 10+ Developers: Valve Corporation

Video Game Directory

181

Possible Diagnoses: Anxiety, autism, OCD, depression Themes: Cooperation, strategy, overcoming obstacles, perseverance, communication Portal 2 is a puzzle platformer game that can be played in one-player or co-op mode. In co-op mode, it is a favorite game to play in therapy with young people. In it, players control robots that are undergoing tests in a facility controlled by a rogue AI named Glados. Each “test chamber” is a challenge based around puzzle-solving and platforming. Specifcally, players use a portal gun which can place gateways (portals) that teleport them from one area to another. Using these portals, good communication skills, and critical reasoning skills, players work together to get from the entrance of the chamber to the exit.

Why Use this Game in Therapy with Young People • • • •

One of the best games for promoting teamwork and communication skills Fun and relatively easy to play for most Promotes breaking larger goals into smaller, more manageable goals Computer AI provides commentary that could be used to process responses to criticism

Unfinished Sentences • • •

My favorite puzzle in Portal 2 is _______. The strength that helps me the most when playing Portal 2 is _______. One thing that makes a difcult puzzle is _______.

Therapeutic Questions • • •

What role do you like to play when playing co-op mode in Portal 2? How come? What might this say about you and how you operate with others? What are some of the communication skills necessary to efectively solve puzzles with a partner robot in Portal 2? Does the AI’s criticism and commentary ever bother you? Make you laugh? If you had an AI narrating your life, what are some of the things it might say?

Ideas for Therapeutic Activities •

Design a puzzle with your client that includes challenges representing the steps necessary to achieve a therapy goal. Process the role the client would play in solving this puzzle and what that means about the type of help/support he/she may require.

182

•

Video Game Directory

Play Portal 2 with your client! The game itself is designed in a way that promotes a collaborative partnership, one of the keys to efective psychotherapy with young people.

Raft Available on PC and Mac Rated: Not yet rated (likely to be E10+) Developers: Redbeet Interactive Possible Diagnoses: ADHD, autism Themes: Multitasking, focus, strategy Raft is a survival game where the player starts out in the middle of the ocean with nothing but a plastic hook. Players use this hook to pull in resources to upgrade their raft and put their survival skills to the test. Players try to live of what is foating around them while avoiding sharks. This game can be played collaboratively or independently.

Why Use This Game in Therapy With Young People • • • • •

Many opportunities for externalizing the problem Many opportunities to work on teamwork/socialization skills Many opportunities to work through the problem Excellent game for groups because of the collaborative gameplay Excellent game for building rapport with clients, also because of collaborative gameplay

Unfinished Sentences • • •

The strategy that works best for me in the game is_______. My favorite resource to fnd in the game is_______ because_______. I can defeat the shark by_______.

Therapeutic Questions •

• •

Have you ever needed a tool in Raft but didn’t have all the resources to make it happen? Did you try to use a diferent tool, or did you continue to develop the frst tool? What did you learn that you could use in real life? Did a problem ever keep attacking your boat like the shark? How did you defend yourself against the problem? What did you learn? Did you ever have to come up with a last-minute strategy in Raft because the shark was about to destroy an important part of your

Video Game Directory

•

183

raft? How did you think quickly on your feet? When have you had to think like this in your real life? When playing Raft with friends, what role do you play to help the group survive? What does this mean about you?

Ideas for Therapeutic Activities • •

Have your client create a tool from resources found around his/her raft that represents one or more of his/her tools/strengths in real life. Have your client create a boat and a shark (representing the problem). Play out what it would be like if the shark attacked the boat and discuss your client’s choices and options for survival.

Ratchet & Clank: Rift Apart Available on PlayStation Rated E10+ for Everyone 10+ Developers: Insomniac Games Possible Diagnoses: Anxiety, depression Themes: Focus, strategizing Ratchet & Clank is a single-player adventure game that takes place in multiple interdimensional universes. Ratchet and his buddy Clank universehop in hopes of defeating an evil emperor who is trying to open a portal to a world where he always wins. Along the way, players meet Rivet who becomes a close ally of Clank’s and sets of on completing several battles. Players can choose between playing as either Rivet or Ratchet while working to fx the damage made by emperor Nefarious.

Why Use This Game in Therapy With Young People • •

Great metaphors representing both strengths and problems Provides opportunities to examine and discuss problem-solving strategies

Unfinished Sentences • • • •

Emperor Nefarious is similar to the problem in my real life because _______. Emperor Nefarious is diferent from the problem in my real life because _______. My life feels like a battle when _______. My favorite universe in Ratchet & Clank is _______.

184

Video Game Directory

Therapeutic Questions • • •

Have you ever needed to develop a new skill to overcome a challenging task in Ratchet & Clank? How did you do it? Have you ever fnally made it past a level you were stuck on? How did that feel? How does it feel to overcome a challenge in your real life? Do you prefer to play as Rivet or Ratchet? How come?

Ideas for Therapeutic Activities •

•

Create a level with your clients that includes challenges they may face when working toward their goals in therapy. Use this level to consider and organize the tools and tactics your client will need to achieve these goals. Create a level representing your client’s journey in therapy. Use this level with your client to gauge progress in therapy.

Rock Band Available on Xbox, PlayStation, Nintendo Rated T for Teen Developers: Harmonix, EA Mobile, and Pi Studios Possible Diagnoses: ADHD, autism Themes: Teamwork, socialization, focus, determination Rock Band is a music video game where players can form a band with friends and put on a concert. With many diferent instruments to choose from, players can add their own fare to create the band of their dreams. Working together with friends, players can learn to master diferent songs.

Why Use This Game in Therapy With Young People • • •

Promotes “accidental social skills” and cooperation Requires perseverance Excellent option for musically inclined clients

Unfinished Sentences • • •

The best way to get better at playing Rock Band is _______. My favorite song to play on Rock Band is _______ because _______. My favorite instrument to play on Rock Band is _______ because _______.

Video Game Directory

185

Therapeutic Questions • • •

Some of the songs in Rock Band are more challenging than others. Have you played a very challenging song before? How did you master it? How long did it take you? What skills/strengths were needed to do that? What instruments do you like playing in Rock Band? Is there a beneft to knowing how to play more than one? How are your (strengths) like instruments? Do you prefer to play Rock Band with others or alone? How come?

Ideas for Therapeutic Activities • •

Set up a band with your client. Encourage the client to choose an instrument that is unfamiliar and set goals to improve. Discuss process of improvement. Group idea: Use Rock Band to create a group of musically likeminded young people.

Rocket League Available on PC, Mac, Xbox, PlayStation, Nintendo Rated E10+ for Everyone 10+ Developers: Psyonix Possible Diagnoses: ADHD, anxiety, autism Themes: Focus, socialization, perseverance Rocket League is an action racing game where the player plays soccer as a car. Players can choose their own car and decorate it any way they want. The game involves steering through the soccer feld and picking up boosts along the way to score a goal. Some games allow players to pick up items like spikes where they can attach the ball to their car and drive it right into the goal. The game is won by having the most points when the timer runs out.

Why Use This Game in Therapy With Young People • •

Ability to express individuality through multiple options for customization Promotes unique approaches to problem solving

Unfinished Sentences • • •

If I was a car on Rocket League I would be _______. If the boost was one of my real-life strengths or skills it would be _______. My favorite/least favorite arena in Rocket League is _______.

186

Video Game Directory

Therapeutic Questions •

•

In Rocket League, it is important to pay attention to your opponent. What are some things you have learned about the opponents you have played against? Did this knowledge help you at all? Were you able to apply this knowledge to future matches? Have you ever been really stuck against a team in Rocket League and unable to beat them? What did you do?

Ideas for Therapeutic Activities •

•

•

Create a match with your client against the problem. Help your client learn how the problem “plays the game.” Talk with your client about diferent strategies for defeating the problem. Play Rocket League with your client. While playing, track your client’s successes (e.g., “You keep blocking the ball!”). Discuss your client’s successes in the game and relate to real-life strengths and skills (e.g., “What do you feel like you have to block in your real-life?” “How do you know when and how to block it?”). Create a boost with your client that represents a set of skills learned in therapy. The boost can include several strategies for a particular situation (similar to the power cards described in Chapter 3).

Sea of Thieves Available on PC, Mac, and Xbox Rated T for Teen Developers: Rare Possible Diagnoses: Autism, anxiety, ADHD Themes: Socialization, teamwork, focus, therapy as a journey Sea of Thieves is an action-adventure game where the player is a pirate who explores the world looking for hidden treasure. While sailing a ship with a crew, players must defend themselves with cannons, swords, and anything else they fnd along the way in their pursuit of riches.

Why Use This Game in Therapy With Young People • • •

Many opportunities to externalize problems Reinforces team-based approach to achieving goals Ample opportunities to work on social and communication skills

Video Game Directory

187

Unfinished Sentences • • •

My favorite/least favorite job on the boat when playing Sea of Thieves is _______. When I fnd hidden treasure, I feel _______. My crew is important because _______.

Therapeutic Questions •

•

There are diferent quest types in Sea of Thieves. What is your favorite? How come? Do you enjoy fnding random crates or getting money? What do you think this might say about you? What is your favorite kind of ship in Sea of Thieves? The Sloop? Brigantine? Galleon? How come? What do you think this means about how you work with others?

Ideas for Therapeutic Activities • •

Have your client create quests against (the problem). Have your client create their ideal crew. Discuss decisions made. What does each person bring to the crew? How can each person help your client achieve his/her goals?

Spiritfarer Available on PC, Mac, Xbox, PlayStation, and Nintendo Switch Rated T for Teen Developers: Thunder Lotus Games Possible Diagnoses: Depression, anxiety, autism Themes: Resourcefulness, problem solving, therapy as a journey Spiritfarer is an adventure game where the player (Stella) fnds souls and completes missions for them. These missions include farming, fshing, gathering resources, creating housing, and cooking, among others. Along with Dafodil, it is the player’s job to help these souls along their surprise-flled journey.

Why Use This Game in Therapy With Young People • • •

Large selection of metaphors Promotes dialogue related to problem solving It has minimal violence but still appeals to mature audiences

188

Video Game Directory

Unfinished Sentences • • •

The character from Spiritfarer that reminds me the most of myself is _______. The character from Spiritfarer that reminds me the most of (the problem) is _______. My favorite/least favorite island to visit is in Spiritfarer is _______.

Therapeutic Questions • •

In Spiritfarer, it is your job to guide spirits and complete missions for them. Has there ever been a mission you were really stuck on? How did you get through it? Although fshing was made to be easy in this game, there are times when it can be tricky. For example, if you are reeling too fast and the fshing rod turns red, it will snap and you will not be able to get a fsh. Why do you think that happens? Why is it important to slow down and pay attention to the tension that’s building on the rod? When you slow down, do you notice how much easier it is to reel a fsh in (even if it takes longer)? What do you think you can learn from this in your real life?

Ideas for Therapeutic Activities •

Create a boat with your client where he/she can take care of spirits. Each spirit should have a specifc need (e.g., self-care, family time, eating, learning, etc.). Work together to think of ways to keep each spirit happy (e.g., “Your self-care spirit is happy when you remember to do some yoga. How could you ft that in this week?”)

Star Wars: The Old Republic Available on PC, Mac Rated T for Teen Developers: Bioware Possible Diagnoses: Depression, anxiety, autism, OCD Themes: Decision-making, problem solving, therapy as a journey Star Wars: The Old Republic (SWTOR) is a massively multiplayer online (MMO) video game that harnesses the popularity and excitement of the Star Wars franchise of movies with the interactivity of an MMO. Players can unite with their friends or battle alone against a variety of enemies in a war for the future of the galaxy. Of particular interest to mental health providers is this game’s fexibility to allow players to

Video Game Directory

189

create their own characters and choose whether they want to serve the light or dark side.

Why Use This Game in Therapy With Young People • • • •

Wonderful array of metaphors for psychotherapy with teens (“Metaphors Be With You!”) Excellent character creation options It has minimal violence but still appeals to mature audiences MMO format provides some opportunities to practice social skills and build community of support

Unfinished Sentences • • •

The type of character that I enjoy playing as in SWTOR is _______. One thing I like about the dark side is _______. One thing I like about the light side is _______.

Therapeutic Questions • • •

How do you compare to the type of character you enjoy playing as in SWTOR? What type of character are you comfortable relying on in SWTOR? How does this compare to the type of person you want to be allies with in your real life? If there really was a dark and light side in your life, what types of decisions would pull you toward each?

Ideas for Therapeutic Activities •

•

Have your client create characters that represent: 1) their ideal self, 2) the way they think others see them, and/or 3) the problem they are working on in therapy. Process decisions made and name these characters for possible use in psychotherapy. Create a dwelling with your clients that represent their personal preferences, strengths, and skills. Discuss how they can adopt more aspects of their SWTOR dwelling in their real lives.

Stardew Valley Available on all consoles, PC, Mac Rated E10+ for Everyone 10+ Developers: Stickhead Games Possible Diagnoses: Depression, anxiety, OCD Themes: Self-confdence, assertiveness, externalizing problems

190

Video Game Directory

Stardew Valley is a simulation game where you inherit your grandfather’s farm and fx it up. There are many mini goals to accomplish on Stardew Valley as well as many villager friends to meet along the way. In this game you get to design your perfect farm and use it to advance in the game at a pace that is just right for you.

Why Use This Game in Therapy With Young People • • • • •

Great metaphors representing constraints to progress Opportunities to externalize problems through monsters Express individuality through multiple options for customization Minimal violence, making it appropriate for most ages and preferences Presents opportunities to talk about family of origin themes

Unfinished Sentences • • •

My goals when playing this game are________ because________. I can persevere on tasks in this game even when they become diffcult by__________. My favorite ways to take care of my farm are __________.

Therapeutic Questions • • •

Have you ever felt defeated from the mines? How did you overcome this? Did you end up beating the level you were stuck on? How did it feel? How are taking care of yourself and taking care of your farm the same? Diferent? Have you ever struggled with completing a big goal like the community center in Stardew Valley? Were you able to fnish it? How did it feel?

Ideas for Therapeutic Activities • • • •

Set up a mine level with your client full of slimes, bugs, ghosts, you name it. Practice strategies (like belly breaths) to help defeat the monsters. Discuss how they did it and how it could relate to the real world. Have your client come up with a plan to take care of her/his “farm” (i.e., something that she/he needs to take care of in real life). Create a community center with your client that has his/her personal goals in each room (the community center is the big goal). Research ways to help the community with your client. Encourage your client to go out and help others in the game.

Video Game Directory

191

Super Mario Bros. Available on all Nintendo systems Rated E for Everyone Developers: Nintendo Possible Diagnoses: Anxiety, depression, OCD, ADHD, autism Themes: Problem solving, skill building, perseverance Super Mario Bros. (SMB) is a platformer game where players run through diferent levels within diferent worlds. At the end of each world, there is a new boss to be defeated. Once players defeat all the bosses, they will face the big boss, Bowser, to rescue Princess Peach.

Why Use This Game in Therapy With Young People • • •

Many opportunities for externalizing the problem Great metaphors to create future-focused language for futurefocused treatment planning Fun and easy for many ages and abilities; widely played and recognized

Unfinished Sentences • • • •

Bowser reminds me of ______ because _______. If I powered-up I would _______. If I could put pipes that brought me to other places in my own life, I would put them_____ and they would take me to_______. I am more like Mario/Luigi (circle one) because _______.

Therapeutic Questions • • • • •

If the (problem) in your life was an obstacle in SMB, what would it be? How come? How do you defeat that obstacle when you play SMB? Is there anything we can learn about that to use in real life? When do you most like to play SMB? What type of mood would you need to be in to want to play SMB? What do you think this means? What non-functional part of SMB would you miss  most if it wasn’t there—the music? The visuals? The way enemies react to the music? Something else? How come? What parts of life do you most enjoy that are not necessary for survival? How come? What might this mean about you? What keeps you playing even though you don’t always succeed?

192

Video Game Directory

Ideas for Therapeutic Activities • •

Design a Super Mario Bros. level that represents the client’s strengths, goals, and obstacles in therapy. There is actually a game called Super Mario Maker that works great to do this with. Set a goal in SMB to accomplish either in-game supported achievements (e.g., collecting coins, beating specifc levels), or a personal challenge (e.g., always running, never running, collecting a certain number of small coins) and achieve it. Discuss the process used to set and accomplish this goal.

Super Mario Galaxy Available on Nintendo Wii and Wii U Rated E for Everyone Developers: Nintendo Possible Diagnoses: Anxiety, depression, OCD, ADHD, autism Themes: Problem solving, skill building, perseverance, focus Super Mario Galaxy is a platform game where Mario travels through outer space to collect power stars. These power stars provide energy to the main hub area of the game known as the comet observatory. To collect power stars, Mario must travel through and complete missions in 42 different galaxies. As with most games in the Super Mario series, the game is won when Mario rescues Princess Peach from Bowser.

Why Use This Game in Therapy With Young People • • •

Fun and easy to play for many ages and abilities Provides opportunities to examine strategies for problem solving Many metaphors that could represent client problems

Unfinished Sentences • • •

If I had to live in a Super Mario galaxy in real life it would be _______. My favorite power-up in Super Mario Galaxy is _______ because _______. The tools that I fnd most useful in Super Mario Galaxy are _______.

Therapeutic Questions • •

What are the tools you need to defeat (the problem)? How did you fnd or learn these tools? My favorite power-up helps me do things in the game I  normally could not. What is something that helps you in real life that you cannot use all the time? How do you know when to use it?

Video Game Directory

193

Ideas for Therapeutic Activities • •

Design a galaxy with your client. Include obstacles representing the problem(s) and tools representing the client’s skills and strengths. Watch the story cutscenes about Rosalina and write a cutscene about a difcult time in the client’s life.

Super Mario Party Available on Nintendo systems Rated E for Everyone Developers: Nintendo Possible Diagnoses: Autism, anxiety Themes: Socialization, acceptance Super Mario Party is a party game where the player is an interactive character on a virtual game board. Players compete in many diferent minigames against friends in order to earn stars and coins. There will be many obstacles along the way that try to stop players from landing on the star spaces, including other players. The person with the most stars at the end of the game wins.

Why Use This Game in Therapy With Young People • • • •

Opportunities to practice social skills Easy and fun for many ages and abilities Includes several possible metaphors to represent the problem Great icebreaker for groups

Unfinished Sentences • • •

My favorite strategy to use in Super Mario Party is _______. I like/don’t like to work with others when playing Super Mario Party because _______. My favorite mini-game in Super Mario Party is _______.

Therapeutic Questions •

•

In Super Mario Party, there are often mini-games that require you to work with someone else to win. When have you had to work with someone else to overcome something in your real life? How did you know that you needed help? How did it go? Some of the mini-games in Super Mario Party require you to play alone against all the other players in the game. Was there ever a time

194

•

Video Game Directory

when you had to fgure something out on your own and it felt like everyone was against you? How did you do it? What mini-game is most challenging for you? Which is the easiest? How come? What skills might you need to help make the more challenging mini-game easier? Can you develop those skills?

Ideas for Therapeutic Activities • •

Have your client design a mini-game to defeat the (problem). Use Super Mario Party as an icebreaker for group therapy with young people.

Super Mario Sunshine Available on Nintendo GameCube Rated E for Everyone Developers: Nintendo Possible Diagnoses: Anxiety, depression, OCD, ADHD, autism Themes: Problem solving, skill building, perseverance, focus Super Mario Sunshine is a platform action-adventure game where Mario, Princess Peach, and a group of toads go on vacation. While on vacation, Mario gets arrested for polluting the island with grafti and is told he must clean up. Items known as shine sprites (source of the island’s sunshine) have disappeared due to the grafti. Mario needs to fnd these by going through diferent levels across the island. Win this game by getting all the shine sprites back and cleaning up all the grafti.

Why Use This Game in Therapy With Young People • • •

Easy and fun for many ages and abilities Opportunities to examine the many ways to work through a problem Great metaphors representing constraints to the problem

Unfinished Sentences • • • •

I am similar to Mario when I _______. I am diferent from Mario when I _______. Something in my life that acts like grafti is _______. The best way to clean up the grafti in my real life is by _______.

Therapeutic Questions •

What strategies did you use when your surroundings changed? How did you come up with those strategies? Did they work? How come?

Video Game Directory

• •

195

In Super Mario Sunshine, goop appears often, and sometimes it takes a really long time to get rid of it. How do you stay patient and get through all the goop? Did you learn anything from this experience? Have you ever needed to work through a problem like Mario has to with the grafti? What was that like? Did you learn anything?

Ideas for Therapeutic Activities •

Create a scavenger hunt with your client to fnd diferent tools (shine sprites) to help them in their quest to defeat the problem. Practice these tools as you fnd them and have the client create some of his/ her own along the way.

Super Smash Bros. Available on all Nintendo systems Rated T for Teen Developers: Nintendo Possible Diagnoses: ADHD, OCD, anxiety Themes: Focus, technique, strategy, knowledge, teamwork Super Smash Bros. (SSB) is a fghting party game where Nintendo characters fght each other with their own special moves. While foating on an ever-changing platform, players are pitted against other characters to battle. There is also an adventure mode in SSB where players unlock new characters and fght their way through a map. This is possibly the most popular game among those participating in gamer groups.

Why Use This Game in Therapy With Young People • • •

Many opportunities for externalizing the problem and work through it metaphorically in the game Can help with considering strategies for overcoming the problem Easy to play and fun for many ages and abilities

Unfinished Sentences • • • • • •

If the (problem) were an arena in SSB it would be _______ because _______. If I had power-ups in real life I would use them _______. _______ is my favorite character in SSB because _______. _______ is my least favorite character in SSB because _______. _______ is the character I am most like because _______. _______ is the character I most want to be like because _______.

196

Video Game Directory

Therapeutic Questions • • • •

Was there ever a time where you needed to power up against (the problem)? How did you do it? Do you prefer improving at the game or having fun? Is winning more important or feeling good about the way you play? What do you think this means about you and how you operate in real life? What tactics and moves do you enjoy using most? Which ones do you succeed with the most? Which ones are the hardest for you to use? How come? How has your opinion of diferent characters changed over time? What does this mean about how you have changed?

Ideas for Therapeutic Activities • • •

•

Have your client create his/her own power-ups against the (problem) and imagine using them in real life. Have clients design smash characters that represent how they think other people see them. Have the client design a smash character that represents her/himself and pit this character against the character that most resembles the problem in SSB. Is there anything that can be learned from this battle? Create a SSB move-set for the client’s real life.

Terraria Available on PC and Mac Rated T for Teen Developers: Re-Logic Possible Diagnoses: Autism, anxiety, depression Themes: Teamwork, building a community of support, overcoming obstacles Terraria is a side-scrolling adventure game where the player gathers resources and money to expand her/his base and make room for new allies. Along the way, there are diferent mobs and bosses to defeat. Terraria can be played alone or with others for a better experience.

Why Use This Game in Therapy With Young People • • •

Great selection of possible metaphors to represent the problem Multiple options for customization Fun and easy to play for most clients

Video Game Directory

197

Unfinished Sentences • • •

My favorite/least favorite thing to do in Terraria is _______. The mob that most reminds me of the problem in my real life is _______. Allies are important because _______.

Therapeutic Questions • •

Some mobs are more difcult than others. What is your favorite mob to defeat? How come? What are some strategies you use to defeat them? There are many diferent allies in Terraria. Who is your favorite ally? How come? What do you do to make sure that ally lives at your base?

Ideas for Therapeutic Activities • •

Imagine with your client that his/her life is a game of Terraria and you must build a base together to defeat the big boss (i.e., the problem). What would the base look like and be stocked with? Have your client externalize the problem as one of the mobs. Discuss what strategies from the game might make sense to use in real life.

The Artful Escape Available on Xbox One, Xbox Series, and PC Rated E 10+ for Everyone 10+ (for reference of alcohol and tobacco use) Developers: Beethoven & Dinosaur Possible Diagnoses: Autism, OCD, ADHD, depression, anxiety Themes: Creativity, mindfulness The Artful Escape is a single-player game featuring a teenage character, Francis Vendetti, who is on a journey to discover himself through music. As Francis, players battle with the legacy of the deadfolk legend intertwined with the celestial stroll of his imagination. Players make decisions about what to do and say with non-player characters while traveling through diferent dimensions. Here, they learn things are not as they seem and must use a guitar to create harmony with the creatures and atmosphere. Francis’s guitar also gives him the ability to jump and run in the game, and he uses it to interact with creatures he meets along the way. Players can customize Francis’s stage name, costume, and what planet he is from.

198

Video Game Directory

Why Use This Game in Therapy With Young People? • • • •

Promotes individuality through choice and customization options Endless opportunities for metaphors Story deals with many themes that are likely to resonate with clients Would be benefcial for those who enjoy music—specifcally jazz

Unfinished Sentences • • •

I am most like Francis when _______. My favorite/least favorite celestial world is _______. The character I like the most in The Artful Escape is _______.

Therapeutic Questions • •

•

How do you choose what to say to other characters in the game? How is this similar or diferent from your real life? Francis goes through a struggle with self-doubt. Have you ever been through a time where you struggled with self-doubt? How did you overcome it? Have you completed a mini challenge in The Artful Escape? How did it feel?

Ideas for Therapeutic Activities •

•

Encourage players to choose interactions and dialogue they normally would not choose. How does this impact gameplay? What about these decisions conficts with your (clients’) normal way of operating? Create a stage character of your client with your client. Process how this character may be similar or diferent from your client.

The Legend of Zelda: Breath of the Wild Available on Nintendo Switch Rated E10+ for Everyone 10+ Developers: Nintendo Possible Diagnoses: Anxiety, depression, OCD Themes: Problem solving, focus, strategy The Legend of Zelda: Breath of the Wild is an open world adventure game. The core gameplay loop is combat, questing, with an overarching antagonist that is the player’s fnal goal. Players spend the game gathering

Video Game Directory

199

weapons and making themselves stronger to face an unknown and powerful threat.

Why Use This Game in Therapy With Young People • •

Many metaphors to represent the problem Story deals with many themes that are likely to resonate with young clients in therapy

Unfinished Sentences • • •

_______ is my favorite weapon type because _______. _______ is my favorite area in the game because _______. My life feels like an adventure when _______.

Therapeutic Questions • • • •

Do you prefer following objectives or going your own way? How come? Is this diferent or similar to how you are in real life? Which city would you most like to live in? How come? Does it remind you of anything in real life? How could you make your real life more like that city? What is your favorite thing to do in the game? How come? Is it something you can do in real life? How could you try? Which champion do you most admire? What is so admirable about that champion? How are you like that champion? Do you want to be more like that champion? What would that look like?

Ideas for Therapeutic Activities • • •

Think about how Link would go through your life if it was an adventure he was on. Collecting things like korok seeds and spirit orbs can help Link on his journey. Start a collection that can help on the client’s personal journey (can be something abstract like knowledge). Try making a puzzle that has meaning to the client and is similar to one that would be in a shrine in The Legend of Zelda: Breath of the Wild.

The Sims Available on PC, Mac, Xbox, and PlayStation Rated T for Teen Developers: Electronic Arts Possible Diagnoses: Autism, anxiety, depression Themes: Socialization, creativity, self-awareness, perspective taking

200

Video Game Directory

The Sims is a sandbox simulation game where players create and control “sims.” Players can make a sim look anyway they want. Once created, sims need to have their basic needs met (e.g., food, water, hygiene, fun, social) and can get a career, a love interest, a friendship, among many other achievements.

Why Use This Game in Therapy With Young People • • • • •

Endless opportunities for metaphors Ability to create many diferent things representing both strengths and constraints Express individuality through multiple options for customization Perfect for many ages and abilities Possibly the best option for creating avatars to represent clients

Unfinished Sentences • • • •

The needs of my sim that I tend to focus on the most are _______. It is important that my sim ______ because _______. I can practice socializing with other sims by _______. My sim is or isn’t like me because _______.

Therapeutic Questions • • •

Have you ever had a sim have a really bad day? How did you help the sim through it? How did you know what the sim needed to make it better? Have you ever created a friendship while playing The Sims? How did you develop that friendship? When you play The Sims do you have a goal in mind that you would like to accomplish? If so, how do you do this? Do you break larger goals into smaller ones?

Ideas for Therapeutic Activities • •

Have clients create sims that represent: 1) themselves, 2) the way they think others see them, and/or 3) the problem. Process decisions made and meaning of choices. Have clients play as the problem and as themselves. Use experiential play therapy techniques to help clients stand up to problems in the game.

Appendix 1

Initial Evaluation With Gamified Language (Part 1)

Client Name:_______________________________ Date(s) of Session:___________

DOB:___________

Client interests: Favorite video games and platform(s): Video game habits including gaming style: Client strengths (including gamer strengths): Future focus (crystal ball question—“What will it look like when it is even better?”): Constraints to future focus: “Are there any video game obstacles that remind you of these constraints?” What has been tried so far to deal with these constraints: What others may not understand about the client:

Appendix 2

Initial Evaluation (Part 2)

Client Name:_______________________________ Date(s) of Session:___________

DOB:___________

Context of presenting concerns: “Is there a video game that reminds you of your life in some ways?” Family’s experience with helpers: Other relevant history: Medical information and risk factors: Mental status: Protective factors: “Are there any video game characters that remind you of yourself?” “How does this character protect itself from danger?” “How would you describe someone like this in real life? Diagnosis: Formulation:

Appendix 3

My Game Design Document (Therapy Plan)

Client Name:_______________________________ Date of Completion:__________ Table A3.1 1. Focus and theme of game (focus of therapy) 2. Early game achievements (short-term goals) 3. Strategy and gaming style (plan) 4. What success in the game looks like 5. What winning the game looks like (epic win?)

DOB:___________

Appendix 4

My Stress-Control Game (Instructions)

This game combines heart-rate variability (HRV) biofeedback (e.g., HeartMath Inner Balance) with a customizable board game to help practice controlling stress responses. HRV is often scored using colors (e.g., red for low, blue for medium, and green for high). The higher (“greener”), the calmer. It can take substantial self-control to change color score in either direction. This game helps players practice that control in ways that ft with their lives.

Game Goal Advance the player piece (e.g., coin, paperclip, fgurine) from the Practice Zone to the Success Zone with no XtraStressPoints.

How To Do It Change your HRV during a HRV session by increasing and lowering it to match the color of the game board section under your player piece. Challenge yourself by holding your HRV in that zone for agreed upon periods of time (e.g., with therapist) before advancing to the next segment. Some segments are touched by StressSplotches that represent good (pink) stress or bad (green) stress that can be labeled with activities or situations. When a segment is touched by a StressSplotch, players must keep their HRV in the matching color zone for extra time to advance. XtraStressPoints are earned when the HRV biofeedback does not match the color of the game board section being played. Players can reduce these by getting really good at changing HRV rapidly.

Game Setup 1.

Choose two activities or situations that you love, you are good at, and you get excited about.

Appendix 4

2. 3. 4. 5. 6.

205

Draw or write something or place an object on the pink splotches on the game board labeled “I get excited when . . .” that represents that activity or situation. Choose two activities or situations you don’t like, you are not good at, and you get worried or anxious about. Draw or write something or place an object on the light green splotches on the game board labeled “I get anxious when . . .” that represents that activity or situation. Choose a playing piece and place it in the Practice Zone. Use the HRV sensor and turn the program on, selecting whatever challenge level you prefer so you are ready to start.

Game Play 1. 2. 3. 4. 5.

With your avatar in the Practice Zone, practice run a HRV session so you can move in and out of the red, blue, and green zones. When you are in the green zone and ready, place your playing piece in the frst (green) segment. Continue to move through the game board by making the HRV biofeedback turn the color of the game board segment you want to progress to. Note any errors in the XtraStressPoint area. Continue to play this way until your playing piece reaches the Success Zone. Add up your XtraStressPoints to get your score. The lower the better.

How Do I Change My HRV? That’s for you to fgure out by changing your breathing, muscle tension, and thinking!

Appendix 5

My Stress Control Game (Game Board)

Appendix 6

Additional Virtual Reality Guided Imagery Scripts

Additional guided imagery scripts that can be read to clients using virtual reality (VR) to experience a forest or beach environment are provided here. Special thanks to Bailey Pilant and Ellen Fichera, two former graduate students in mental health counseling, for helping write these scripts and testing them with standardized patients. The current scripts are intended to promote concepts in mindfulness, whereas the scripts embedded in Chapter 10 were written with a focus on general relaxation. Three-dimensional forest and beach scenes are available on YouTube VR, Google Earth VR, and through emerging health software designers (e.g., XR Realms). These scripts are intended to be read slowly.

Mindfulness Forest Scene Take a moment to get in a comfortable position and notice your surroundings. [Pause 10 seconds] Start by taking a few deep breaths—inhale through your nose for fve counts [pause fve counts], hold for fve counts [pause fve counts], and release through your mouth for fve counts [pause fve counts]. Repeat this breathing once more, focusing on breathing through your heart area. In through the nose . . . 1,2,3,4,5 . . . hold 1,2,3,4,5 . . . and release through the mouth 1,2,3,4,5. Continue breathing like this. [Pause 10 seconds] Notice the warm air leaving your mouth as you exhale. Notice your lungs working to release air and any tension you may feel. Simply notice how your body feels at this moment. Let your thoughts come and go without judgment. They are only thoughts. [Pause 10 seconds] Take a look around your environment. What do you notice? What catches your eye? Notice how your body feels at this moment. [Pause 10 seconds] What sensations do you feel? Has your body become tense? If so, allow it to relax. Now allow your mind to travel from your feet [pause 5 seconds],

208

Appendix 6

through your legs [pause 5 seconds], allow any tension or discomfort to go unnoticed as you continue to follow your energy through your abdomen [pause 5 seconds]. Now slowly bring your focus up through your chest, through the back of your head, and into your forehead. Continue to allow unwelcome feelings to pass without judgment as you continue breathing through your heart area. You are in control. [Pause 10 seconds] Notice the forest and Mother Nature at work. The environment brings complexity and may invoke feelings of danger. Pay attention to those things in the forest that may invoke feelings of danger or fear. Whatever feels right to you is fne. Remember, you are in control. Imagine the forest as a metaphor for a complex situation you may be facing in your life. You have the ability to conquer your fears. You have the ability to take control of your environment. Again, simply notice without judgment. Allow your thoughts to come and go. [Pause 10 seconds] Focus on grounding yourself with the environment. Do you feel a cool breeze or hear the rustle of the trees? Breathe through your heart area like you practiced in the beginning [pause 15 seconds]. Thank your body for working with you through this experience. Allow your body to become one with the forest around you. [Pause 10 seconds] Find one thing in the forest you appreciate. Imagine you are inhaling this feeling of appreciation [pause fve counts], allow any discomfort to exit your body through your exhale [pause fve counts]. Send appreciation through your body for all it does to serve you. [Pause 10 seconds] Choose to remember this experience in the forest. Remember the feeling of appreciation and what it was like to have compassion for yourself. Applaud yourself for conquering your fears in the forest [pause 5 seconds]. On the next exhale, focus on your sensations, including those outside of the forest—your feet on the ground, the temperature of the room, the VR headset. You can choose to focus on any of these sensations. You are in control and can choose to stay or leave the forest as you wish.

Mindfulness Beach Scene As you begin this practice, allow yourself to feel gratitude for taking time to yourself [pause 5 seconds]. You are taking this time to be present. In these frst couple of moments, allow yourself to feel where you are in the mind and body [pause 5 seconds]. As you settle into the space, start to bring focus to your breath [pause 5 seconds]. Focus on the air you are breathing in. Notice your abdomen expand as you create more room in your lungs for air; your body relaxing as it welcomes oxygen. Allow

Appendix 6

209

any sensations or thoughts to exist without judgment [pause 5 seconds]. Shift your focus to your exhales [pause 5 seconds]. With every exhale, release yourself of anything that is no longer serving you. [Pause 10 seconds] Check in with your body, feeling any sensations, holdings, or tightness [pause 5 seconds]. Begin to notice your mood, your emotions [pause 5 seconds]. Acknowledge what is being felt without judgment and feel gratitude for your emotions. [Pause 10 seconds] Begin to send your attention toward your surroundings [pause 5 seconds]. What is the frst sound you hear? Pause for a moment and listen to the complexities of the diferent noises, the sound of the ocean [pause 3 seconds], the wind [pause 3 seconds], the birds [pause 3 seconds]. The things you wouldn’t normally or aren’t supposed to hear. Allow yourself to just listen. [Pause 10 seconds] Bring yourself back into your body and feel what is around you with a renewed sense of appreciation [pause 5 seconds]. Imagine the sun is your closest loved one hugging you [pause 3 seconds]. Let yourself feel the warmth of the sun as it embraces you. [Pause 10 seconds] Notice the gray clouds on the horizon [pause 3 seconds]. Watch as they threaten to cover the sun, taking away your warmth [pause 3 seconds]. Acknowledge the clouds and the darkness they carry with them [pause 3 seconds]; the rain that will inevitably pour out of them [pause 3 seconds]. Now shift your attention to the plants and their intricate colors. Find a color that flls you with a sense of calm [pause 5 seconds]. Feel appreciation for the clouds and rain that allow these plants to grow and thrive [pause 5 seconds]. Feel the warm embrace of the sun and allow your attention to remain on the breaks of sun in the clouds. [Pause 10 seconds] Choose to remember this experience on the beach. Remember the feeling of appreciation and what it was like to have compassion for yourself. Applaud yourself for conquering your fears [pause 5 seconds]. On the next exhale, focus on your sensations, including those outside of the beach—your feet on the ground, the temperature of the room, the feeling of the headset. You can choose to focus on any of these sensations. You are in control and can choose to stay or leave the beach as you wish.

Appendix 7

Video Game Controller Imagery Worksheet (Xbox Version)

Instructions If you had a video game controller that you could use to get through your real life, what would the buttons do? Use the controller below to label the buttons (e.g., B = breath, A = assert self, etc.). When you are done, use the lines below the controller to describe any combinations (e.g., Up plus B and A = Challenge OCD). Feel free to change the buttons or add buttons if you prefer. You can draw new lines to label buttons that are not already on the controller. You can also use the reverse side of this worksheet to add more combinations.

_______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________

Appendix 8

Video Game Controller Imagery Worksheet (Switch Version)

Instructions If you had a video game controller that you could use to get through your real life, what would the buttons do? Use the controller below to label the buttons (e.g., B = breath, A = assert self, etc.). When you are done, use the lines below the controller to describe any combinations (e.g., Up plus B and A = Challenge OCD). Feel free to change the buttons or add buttons if you prefer. You can draw new lines to label buttons that are not already on the controller. You can also use the reverse side of this worksheet to add more combinations.

_______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________

Appendix 9

Video Game Controller Imagery Worksheet (PlayStation Version)

Instructions If you had a video game controller that you could use to get through your real life, what would the buttons do? Use the controller below to label the buttons (e.g., B = breath, A = assert self, etc.). When you are done, use the lines below the controller to describe any combinations (e.g., Up plus B and A = Challenge OCD). Feel free to change the buttons or add buttons if you prefer. You can draw new lines to label buttons that are not already on the controller. You can also use the reverse side of this worksheet to add more combinations.

_______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________ _______ + _______ + _______ = _____________________

Appendix 10

Video Game–Themed Treatment Plan Template

Table A10.1 Table A10.1 Template for creating a video game–themed treatment plan (same as Table 2.1) Level One

Level Two

Level Three

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1 point = 2 points = 3 points =

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1 point = 2 points = 3 points =

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1 point = 2 points = 3 points =

Environment/setting Main characters

Tools needed

How to earn points Level won when

Appendix 11

Video Game Therapy Ideas Worksheet

Video Game Title: Available on ______________________________________ Rated (circle one) E E10+ T M Possible Problems: ________________________________ Themes: _________________________________________

Brief Description of Video Game: Why Use This Game in Therapy? • • •

_____________________________________________ _____________________________________________ _____________________________________________

Unfinished Sentences • • •

One thing I like about this game is _________________. One thing I don’t like about this game is _________________. _____________________________________________.

Therapeutic Questions • • •

__________________________________________________________? __________________________________________________________? __________________________________________________________?

Ideas for Therapeutic Activities (use reverse if needed):

Appendix 12

Tips for Parents of Gamers

Clinician Instructions Give this tip sheet to parents of young gamers to provide a starting point for how to make decisions about gaming-related mediation. • • •

•

•

• •

Consider using two hours as a starting point when determining maximum screen time. Be sure to consider your child’s level of functioning (e.g., academic, social) when making decisions about screen time. Some children can function efectively with more screen time than others. Entertainment Software Review Board (ESRB) ratings can be a helpful resource when determining which games are suitable for your child. It is always advised to learn about the video games that your child(ren) likes to play. That said, you must go further than the rating on the box, as they are often inconsistent. For young people who are at risk for nature-defcit disorder (ask your mental health provider for more information on this), consider requiring an equal amount of time spent outside or doing something active as is spent playing video games. When using video games or screen time as a reinforcement for positive behavior, establish a minimum amount of time that is not contingent on behavior to avoid problematic responses and power struggles while keeping your child motivated to improve the behavior he/she is working on. Also, when using video games or screen time as a reinforcement for positive behavior, be sure to build plans based on earned (as opposed to lost) screen time. Ask your child(ren) questions about who they play with online (if applicable). It is ok to set limits on who your child can game with online. At the same time, online gaming is a regular part of youth socialization these days and should not be eliminated or limited without ample discussion and thoughtful decisions based on safety.

216

• •

•

• •

• •

Appendix 12

Encourage your child(ren) to think critically about what they share and do when gaming online. Remind them that nothing is ever really “deleted” from the internet. Have regular discussions about internet safety and in-app purchases with your child(ren). Set strict limits on in-app purchases and encourage your child(ren) to think critically about what they pay for online. Explain what scammers and hackers are. Encourage your child(ren) to talk to you or another trusted adult if they are ever worried or upset about something related to gaming. Try to resist banning games completely when this happens so your child is not discouraged to ask for help in the future. Consider requiring that your child(ren) refrain from gaming for a full day either weekly, bi-weekly, or monthly (depending on what is reasonable and realistic for your child). Do not dismiss your child’s interest in pursuing video games as a career. The video game industry ofers many viable options for employment these days and can encourage young people to learn skills like coding that are highly transferable to other professions. Play video games with your child and ask her/him about game preferences! They listen diferently when you are sitting side by side! Remember that above all else it is your role to be a parent (not therapist, friend, etc.)!

Appendix 13

Let’s Play Reflection Worksheet

Client Name: Let’s Play Name:

Date of Birth: YouTuber/Timestamp:

In what ways do you relate to what the YouTuber was saying when he was talking about (anxiety, depression, etc.)? What did you learn from listening to the YouTuber’s experience? In what ways did you relate to the YouTuber? If you could give the YouTuber advice, what would you say? Is there anything you think this YouTuber could advise you on? If you had to choose a video game to pair with your experience, what would it be? How come? What about what the YouTuber said did you not agree with? How come? Would you recommend this Let’s Play to a friend going through a similar experience?

Index

Note: Page numbers in italic indicate a fgure and page numbers in bold indicate a table on the corresponding page. abdominal breathing 45, 46, 54, 114, 126, 140 abdominal expansion 49 Adaptive Behavior Assessment System (ABAS) 84–85, 89 adherence to treatment 67 aggression 8, 29, 117 American Society of Clinical Hypnosis 108 Among us 140–141, 153, 154 anger 17, 95, 106 anime: anxiety and depression 75; drawings 76; females, ASD 74, 76–77; Reborn series 75 anxiety/anxiety disorders 13, 137; avatars, clients and 55–56; in DMDD 22; fear 52–55; fight 123; Game Grumps 96; psychotropic medicines 60–62; SSRIs 60; treatment, video games 6–8; treatment plan, video game–themed 53, 54, 54–55; Up and Down the Worry Hill 58–60; video game–themed ERP 56–57; VR 121, 122 appreciative ally 16 apps: BoosterBuddy 115; Emotionary 116; Headspace 115; Manatee and Me 116; meditation 116; My Life 115; RR 112–116 AR see augmented reality (AR) ASD see autism spectrum disorder (ASD) Asperger syndrome 66, 76 Assassin’s Creed 7–8 assessment: anxiety 55; integrated approach to gaming 18; situational memories, VR 121, 122

attention defcit hyperactivity disorder (ADHD): exercise and activity 137; nature, treatment plan 144; treatment, video games 6–8 augmented reality (AR) 120, 138 autism 6–8; avatars, diagnosis 74–77; gamifying non-preferred activities 70–71; video game controller imagery 72–73; video game music 68–70; zoning out 69 autism spectrum disorder (ASD) 102; anxiety and OCD, high prevalence of 52; electronics use 66–67; fear of poison ivy 23; gaming in therapy 67–68; interpreting metaphors 78; metaphors 23; obsessive thought 26; and OCD 23; prevalence 81; repetitive behaviors 29; social inclusion skills 81; social media use 67; social skills 77; VR 130–132 autonomic nervous system 38, 39, 42, 45, 48, 49 avatars: anime 74–77; diagnosis, autism 74–77; reaction, trigger in game 110; The Sims 74 Beat Saber 126 Big Bass Fishing 142–144 big boss 28–29, 53, 56, 62 biofeedback 5, 10, 13–14; anxiety/ stress 40; board game 47; equipment 49; HRV 39; pairing video games 42–44; sensor 16 biomarkers 38, 48 biome 30, 31, 33, 173 bipolar process 22

Index BoosterBuddy app 115 breath-rate 49 calibration: abdominal breathing and mindfulness skills 46; PSR 45; remembering 48–49; transition-age youth, ASD and OCD 45–46 Call of Duty 72, 73 CBT see cognitive behavioral therapy (CBT) CBT-SD see cognitive behavioral therapy with systematic desensitization (CBT-SD) celebrating success 34, 89 Celeste 106 character interpretation 62 characterize(ation) 12, 35; avatars creation 112; externalization 22; mental illness 21–24 characterized problems 36 client strengths 21, 25, 85–86 cognitive behavioral therapy (CBT) 3, 20, 52, 116; CBT-SD 122; GAME, OCD 59; panic, anxiety and OCD treatment 13; RIDE 54, 58; unhelpful thinking 13; VR application 122 cognitive behavioral therapy with systematic desensitization (CBT-SD) 122 connection to nature 145 conscious breathing 18 constraints 40, 49; ERP planning 56–57; psychotherapy groups 83 co-op games 42–43, 81 COVID-19 pandemic 77, 104, 121, 130 crystal ball question 16–17, 143 daydreaming minigames 110, 111 deconstruction 88, 163, 170 defying OCD 58, 59 Depression Quest 106 diagnosis: choosing game 42; LPs 97 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 23, 28 diagnostic interpretation 23, 24, 28, 29 dialectical behavioral therapy (DBT) 125 disruptive mood dysregulation disorder (DMDD): behavioral outbursts 40; the Termites and the Mooing Men 22; video game–themed treatment plan 40–41

219

DMDD see disruptive mood dysregulation disorder (DMDD) Donkey Kong 70 driving-related anxiety 123 eating disorders 121, 122 EBay 6 Ecotherapy 145 ego-dystonic (externalized) 21–22, 28, 56 ego-syntonic (internalized) 21, 28, 74 Emotionary app 116 emotion regulation 38, 136 EndeavorRx 116, 117 enforcing rules 43–44 Entertainment Software Review Board (ESRB) ratings 150, 215 equipments, integrated approach to gaming 15–16 ERP see exposure and response prevention (ERP) exercise 115, 116, 136, 137, 142 expert 46, 50 exposure and response prevention (ERP) 13; confronting fears 56–57; video game–themed plan 57; VR, anxiety and OCD 124 exposure therapy 123–124 extended reality (XR) 120 externalize(ation) 13, 17, 21–22, 86 externalized 22, 29, 87, 101, 112, 114 FDA approval, serious games 116–117 fear: behavioral-based 56; exposure treatments, fying 123; of noxious fora 23, 24; sensory level 56; VR, use of 121 function of behavior 56, 63–64 GAME approach 59, 124, 140 GameCube 85 game design/development: defning 109–110; evidenced-based 110, 112; faculty member 110; interprofessional design 107–108; language barriers 109; mental health games 108–112; MG 107–112; prototyping 110; scoping and tiering 110–111 game design document 203 Game Grumps 96 gamer: clients 10, 13, 19, 48, 84, 139, 141; metaphors 56; parents, tips for 215–216

220

Index

Gamer Club 91 gamer group: consoles 85; curriculum 85–89; psychotherapy 83–84; qualitative data 84; results 89–90; social skills 81–82; support 82–83 games for health 105; funds 117–118; MG 107–112; serious games, mental health 105–107 Games for Health and Cyberpsychology 78 Games for Health Europe conference 105 gamify(ication) 13; afrmations and gratitude routines 105–106; homework 112; non-preferred activities 70–71, 71 gaming, psychotherapy: ASD 67–68; assessment 18; CBT 13; client’s gaming preferences 14–15; crystal ball question 16–17; equipment needed 15–16; mindfulness 13–14; NT 13; practitioners, treatment guide 15; sessions 16–19; therapist missions 20; video game–themed treatment plan 18, 19 gaming journal 18 GARS see Gilliam Autism Rating Scale (GARS) geocaching 139 gestalt “empty chair,” 97 Ghostbusters 23 Gilliam Autism Rating Scale (GARS) 76 Grand Theft Auto V, 9 Gris 106 group curriculum: age group modifcations 90; deconstruction, process of 88; externalization 86–87; gamer tag 86; identifed strengths, reinforcement 86; integration, externalized character 87; navigating obstacles 87; obstacles 88; parent form, ABAS 85; personal strengths assessment 85; power cards 85–86; reauthoring 89; skills 85; successes celebration 89; supporting members 88–89; unfnished sentence 85, 86 group psychotherapy 83–84 guided imagery: scripts 207–209; and VR 126–127 Halo 4, 81 Headspace app 115 HeartMath Laboratories 39

heart rate 38, 39, 49 heart rate variability (HRV) 39, 43, 44, 47, 48, 204, 205 Hellblade: Senua’s Sacrifce 106 hoarding behaviors 33, 143 HRV see heart rate variability (HRV) Imagery: Re-Mission video game 61–62; and VR 126–127 increasing difculty 44 initial evaluation 201, 202 Insight Timer-Meditation app 116 integrated approach, gaming: assessment 18; CBT 13; client’s gaming preferences 14–15; crystal ball question 16–17; equipment needed 15–16; mindfulness 13–14; NT 13; practitioners, treatment guide 15; sessions 16–19; therapist missions 20; video game–themed treatment plan 18, 19 integration 13, 38, 84, 85, 87, 88, 112 internalized 21, 56, 69, 74 International Meeting for Autism Research 108 interprofessional game design: goal-based imp 107; mental health games 108–112; MG 107–112; problem-based imp 107 language barriers 109 Last Child in the Woods (Louv, Richard) 135 League of Legends 96 Lego series 81 Let’s Play (LP) 83, 84; client refections 100; counseling 96; creator(s) 95; depression 95; efectiveness, therapy 100–101; future research 101; Game Grumps 96; gameplay 95; internet safety 103; psychoeducation 101; psychotherapy 94, 97–100; selected 97, 98–99; strengths assessment 97; success 95; therapist missions 104; video selection 97; young people 94 local play 141–142 logic 26 long-term efects, violent video game play 9 LP see Let’s Play (LP) Manatee and Me app 116 Mario Kart 40

Index massively multiplayer online role-playing game (MMORPG) 67–68 MEATS 63 Media and Youth: A Developmental Perspective (Kirsh, Steven) 138 meditation: app 116; VR 125–126 mental health: serious games for 105–107; YouTube videos 93–94 mental health games: designing 108–112; MG 107–108 metaphors: anxiety 21; character interpretation 35; confusion 21; externalize and “characterize” mental illness 21–24; Ned’s video game–themed treatment plan 34; organize and remember, strengths and skills 24–28; Pokemon 53, 54; relationship, client and problem 28–29; social learning 29–33; therapist missions 36; Up and Down the Worry Hill 58–60; video game–themed treatment planning 33–34 Mighty Ducks; Game Changers 142 MindFit Experts 83 mindfulness 13–14, 46; beach scene 128–130, 208–209; forest scene 127–128, 207–208; VR 125–126 MindGamers in School 29, 74 MindGamers (MG): animated triggers 107; avatar creation 107; defning design 109–110; gameplay 108; goal-based imp 107; language barriers, crossing 109; minigames 108; problem-based imp 107; self-regulation skills 107; setting process and scope 110–111 Minecraft 22, 28, 29, 30, 33, 40, 125, 139 mini-boss 21, 35, 53, 56, 62 minigames 108, 110 misdiagnosis 23 mission: creation screen 113; development 114; integrated approach, gaming 20; record text 113; review progress 115; RR 112 mixed reality (MR) 120 MMORPG see massively multiplayer online role-playing game (MMORPG) MR see mixed reality (MR) My Life app 115 My Self-Control Game 47–48

221

narrative therapy (NT) 13 nature-based: therapy 144–145; video games 142–144 Nature-Based Therapy; The Nature Fix 145 nature defcit disorder: Among us 140–141; argument for nature 136–137; defnition 135–136; exercise, activity, anxiety, and ADHD 137; gaming’s impact, young people 138–139; geocaching 139; local play 141–142; nature-based therapy 144–145; nature-based video games 142–144; Pokemon Go 138–139; real-life Minecraft 139; role play 139–140; therapist missions 145; Zombies, Run! 142 NeuroRacer 116 Night in the Woods 106 Nintendo Game Boy 6, 7 NT see narrative therapy (NT) obsessive-compulsive disorder (OCD) 13; “Bothers” and the “Fox,” 26–28; the Claws 23–24, 28; compulsive behavior 29; confronting 60; defying 58, 59; Enjoy your success 60; intrusive thoughts 29; obsessive thought 26; psychotropic medicines 60–62; reverse compulsion 60; RIDE technique 58–59; video game music 68–70; VR 121 obstacles 87, 88 Occulus Quest 124, 126, 130 OCD see obsessive-compulsive disorder (OCD) Pac-Man 70–71 pairing video games, biofeedback: choosing game 42–43; enforcing rules 43–44; establishing rules 43; increasing difculty 44 pandemic 77, 104, 121, 130 panic 13 perseverations 56, 69 pervasive developmental disorder 66 physiological sigh technique 73 player types 18 play therapy 7, 12 pleasure-seeking 69, 74 points 36 Pokemon 83, 88 Pokemon Go, MR game 120, 138–139 Pokemon metaphors 53, 54

222

Index

portable devices 141–142 Portal 2, 81 power cards 26–28 power-up 46 preoccupation 23, 29, 56, 69, 74 problem-based imps 29, 74 process of design: clinical team and development team 109; interaction, imps 110; MG 107–108; prototyping 110; setting process and scope 110–111 prototyping 110 PSR see psychophysiological self-regulation (PSR) psychoeducation, chronic disease management 3 psychopharmacological interventions 22, 53, 60, 61, 62, 63 psychophysiological self-regulation (PSR) 38, 40, 41, 45, 48, 63, 107; meditation and yoga 13; mindfulness 13–14 psychotherapy: BoosterBuddy app 115; Emotionary app 116; groups 83–84; LPs 96–100; Manatee and Me app 116; meditation app 116; My Life 115; RR app 112–115; side-by-side 5; vanity apps 115; video games 3–5 psychotropic medicines 53, 60–62, 63 rage 29–30, 40 Rayman 81 reauthoring 13, 89 Rec Room 131–132, 132 refection worksheet 217 Re-Mission 60, 61 renaming thoughts 59 Repetition Rebellion (RR): characterizer screen 112; introduction 114; journal screen 113–114; main menu 112; mission creation screen 113; mission development 114; problem externalization 114; review implementation and refne 115; utility belt screen 112; vanity apps 115 repetitive behaviors 29, 45–46, 56 RIDE, CBT technique 54, 58, 59, 60 risk-avoiding 69 Rochester Institute of Technology (RIT) 108 role play 139–140

schizophrenia 121, 122 scope of design 110–111 screen time 62, 63 Sea of Solitude 106–107 self-monitoring 36 self-regulation skills 42; MG 107; My Self-Control Game 47–48 self-regulation training, video games: biofeedback 38–40; calibration 44–46; case of Sam 40–41; My Self-Control Game 47–48; pairing video games, biofeedback 42–44; therapist missions 50; video game–themed treatment plan 40–41 sensor 40; biofeedback 38, 39, 43, 44, 49; HRV 39, 43, 44; Inner Balance 39, 47 serious game 105; Celeste 106; Depression Quest 106; FDA approval 116–117; Gris 106; Hellblade: Senua’s Sacrifce 106; mental health 105–107; Night in the Woods 106; Sea of Solitude 106–107; therapist missions 118 side-by-side psychotherapy 5 skills: power cards 26–28; psychophysiological self-regulation 25–26 social anxiety: managing, video game controller technique 72–73; VR 125–126 socialization 68, 80, 82, 84 social learning: “Jimmy the Creeper Gets Mad” 30–33; physical aggression 29; self-regulating, competitive situations 29 social media 3, 67, 93, 94 social skills: ASD people 77; co-op games 81–82; members’ behavior 82; young people, ASD 81 social story(ies) 29 stress-control game: changing HRV 205; game board 206; game play 205; goal 204; HRV session 204; setup 204–205 stress response(s) 47 Super Mario Brothers 7, 8, 46, 69 Super Mario games 46 Super Smash Bros. 82 support groups: MindFit Experts 83; video games 82–83 teaching calibration, video games 44–46

Index technology in nature: Among Us 140–141; geocaching 139; nature-based video games 142–144; outdoor local play 141–142; Pokémon Go 138–139; real-life Minecraft 139; role play 139–140; Zombies, Run! 142 technology specifcations 7–8 therapeutic process 21 therapeutic relationship 4, 11, 96, 101 therapist missions 20 therapy plan 203 toolbox 47 tools 21, 24–26, 33, 36 trance 23 transition-age youth 23 Up and Down the Worry Hill 58–60 veterans, post-traumatic stress 121 video game controller imagery: ASD 72–73; game controller user’s manual 72; instructions 210; platform 72; social anxiety 72, 73; worksheet, PlayStation version 212; worksheet, switch version 211; worksheet, Xbox version 210; Xbox controller 72 video game music: ASD and OCD 68–70; gamifed shower 69–70 video games: externalization 21–22; psychoeducation 3, 4; side-byside psychotherapy 5; subculture 4; as subculture 4; therapeutic relationships 4; therapy ideas worksheet 214; violent behavior, young people 8–10 video game–themed treatment plan 18, 19, 33–34; anxiety disorders 53, 54, 54–55; ASD and OCD 71; self-regulation training 40–41; template 213 video selection, LP 97, 98–99 violence, video games 8–10

223

virtual reality exposure therapy (VRET) 122, 123 virtual reality (VR) 14; advantages 122; applications and evidence 121–122; beach scene 128, 128–130; dog phobias, children 121; entertainment purposes 120; exposure therapy 123–124; forest scene 127, 127–128; group therapy 81, 90–91; guided imagery 126–127; headset 133; health care 120; meditation and mindfulness 125–127; mindfulness 207–209; psychotherapy, young people 132–133; scripts, guided imagery 207–209; social anxiety 125–126; therapist missions 133; veterans, treating of 121; virtual sessions 130–132 virtual sessions 130–132 VR see virtual reality (VR) VRET see virtual reality exposure therapy (VRET) walk and talk therapy 5 Walking Dead, The 115 Wander 125, 126 Wii 85, 87, 88, 89 Working with Video Gamers and Games in Therapy (Bean) 18 World of Warcraft 81 XR see extended reality (XR) YouTube 68, 78, 84; educating young people 93; mental health 93–94; social connection 94 YouTuber: Game Grumps 96; selected LPs 98–99 Zombie Nation 25 zombies 53 Zombies, Run! 142 zoning out 69