The serious game that provides CBT: Dr Mathijs Lucassen discusses SPARX

Computerised cognitive behavioural therapy (cCBT) is a low-intensity psychological intervention that can be one step of treatment for mild-to-moderate-severity depression. It is a way of delivering CBT to people through computer devices, typically as a self-guided set of sessions. Despite using computers, cCBT might fall short of young people's expectations when it comes to interactivity. That's where SPARX ('Smart, Positive, Active, Realistic, X-factor thoughts') comes in.

SPARX is a set of seven cCBT sessions in the form of a fantasy-themed video game, developed for young people with mild-to-moderate depressive symptoms. In a randomised control trial with 187 participants aged 12-19 with mild to moderate depression, SPARX was at least as good as treatment as usual (Merry, 2012). When treatment as usual typically requires a lot of face-to-face contact with trained staff, it's promising to see an intervention that could be as effective, but is far more accessible.

The video game features 3D graphics and plays like a role-playing adventure. While clinical software can often look embarrassingly out of date, this game doesn't look too out of place among mid-budget indie titles, which players are accustomed to. As the player controls the avatar across seven distinct levels, they explore an overarching story while interacting with characters who explain CBT concepts, teach the player skills and strategies, and give the player 'homework' to try those strategies while away from the game.

A character takes the player through a breathing exercise

A spark of an idea

I discussed SPARX with Dr Mathijs Lucassen, Senior Lecturer in Mental Health (Open University) and Honorary Academic (Department of Psychological Medicine, University of Auckland), who was part of the team that developed SPARX at the University of Auckland. He explained that SPARX is the brainchild of Professor Sally Merry, a child and adolescent psychiatrist who holds the Cure Kids Duke Family Chair in Child and Adolescent Mental Health at the University of Auckland. General Practice colleagues were telling her they needed better access to CBT for young people with depression in New Zealand. 'They were asking 'can't you do deliver it somehow on a CD ROM or something?'' Mathijs said.

Dr Mathijs Lucassen

At the time Prof Merry was supervising Dr Karolina Stasiak, who had worked on The Journey, which Mathijs notes was one of the first examples of game-based CBT. The Journey had used elements of 2D gaming to encourage user engagement, with an overarching fantasy story of a character travelling to their homeland (Fleming, 2014). The player would complete lessons and quizzes to progress, and would be rewarded with simple mini-games at the end of each module. It's easy to see the DNA of The Journey in what SPARX would eventually become. 'It was not as sophisticated in terms of graphics or interactivity as SPARX is,' Mathijs said, 'but the feedback from the young people and from the school guidance counsellors was really positive.' They were wanting more.

The New Zealand Ministry of Health approached Prof Merry about how they could make psychological therapies more accessible to young New Zealanders. They had seen The Journey and were keen to build on it. Thus SPARX was born. The project received funding from The Prime Minister's Youth Mental Health Project to make the program available across New Zealand, and SPARX has even featured on the Ministry of Health's website.

Mathijs, Dr Theresa Fleming and Dr Matthew Shepherd, who all did their doctoral projects on SPARX with Prof Merry, come from working in Child and Adolescent Mental Health Services. 'So we were acutely aware of how therapy is not being accessed by those people in the mild to moderate range,' Mathijs said. SPARX was intended to address this accessibility issue.

Obstacles to therapy

I asked about the barriers that New Zealand youth face to accessing therapy in the community. 'I think it's about recognition in young people,' Mathijs said. 'Some of the symptomatology is going to be different. They might present as more irritable and people aren't picking that up as a feature of depression. Even if people are recognising that they have issues in terms of their mood, a lot of the time people will think they can sort it out themselves or with friends or family and it's not until things get to be quite worrisome that they will seek formal help. Part of that is to do with stigma; I think that they would access help more readily for a physical health concern than they will for a mental health concern.'

Beyond that, there are systemic barriers, also. 'It's about knowing how to access services,' Mathijs said. 'In schools, it does help to have support available. If they aren't available, it's pretty tricky for a young person, because they'll need to have a family that is going to support them to go see their GP. There are all sorts of complexities in there for young people because they're not emancipated adults, but even if they were, there are certain challenges. New Zealand is about the same size as the UK but it has less than 10% of the population, so people are often at distance from their school, their GP surgery, and most of the therapists will be in the bigger urban centres. You could be hours away from Christchurch living in the rural South Island and it will be difficult for you to access those services.'

One aspect that vastly improves accessibility to SPARX is that it can be freely downloaded on the internet, without a need for a prescribing clinician. 'Clinicians often feel that they have to gate-keep therapy,' Mathijs said, 'and that can become a barrier in itself. Also, to have someone provide a referral, they'd have to know about the intervention and they'd have to be willing to support the intervention, so that means a lot fewer people would be able to use it.'

While SPARX can be accessed without clinical contact, there is 24-hour clinical back-up support provided in partnership with Youthline and Lifeline, a phone line staffed by professional counsellors, and additional resources are also available online. Mathijs said that people are using SPARX as a sole mode of therapy, but some are also using it as an adjunct to their conventional treatment.

The game's open availability has given it an impressively wide reach. About 1% of young people in New Zealand have registered to use it, Mathijs estimates, and this might well be an underestimate. This represents an incredible reach to the young population, especially for a clinical game. Surely many game developers would dream that 1% of young people would play their game.

Cultural relevance

With such wide use, the game is played across cultures, which is something the team considered during development. Researchers on the team worked collaboratively with young people during development. One of the SPARX team, Dr Matthew Shepherd, a clinical psychologist, focused on the design and applicability of the program for Māori adolescents. 'It was interesting,' Mathijs said, 'because the feedback from the young people and their families was that they would have liked to have been involved and have worked through this together. This is more of a collectivist approach to helping someone with their challenges, which fits much more with the Māori approach. Of course, playing games is not necessarily an individual thing, as you can play with others, but you wouldn't necessarily think you'd be playing with others in your family all the time.'

This contrasts with Mathijs's work with SPARX focusing on lesbian, gay, bisexual and transgender (LGBT) youth, where the private nature of the game is seen as one of its biggest strengths. 'They can do this alone and their family don't need to know,' Mathijs said. 'Some young people unfortunately can't talk openly with their families, and are having to navigate quite complicated dynamics as a result of that.' An adapted version of SPARX for LGBT youth called Rainbow SPARX has been developed, which is largely the same in terms of CBT content, but features an adapted script which makes the story more relevant to LGBT youth and the difficulties they face. Rainbow SPARX was rated favourably in terms of acceptability by young LGBT users, with over 80% saying it would appeal to young people and that they'd recommend it to friends.

SPARX's appeal to New Zealand youth also relates to the game's local cultural content. 'Usually they're bombarded with American and British and Australian popular culture.' Mathijs said. 'Māori young people recognise more things in the game because Matt Shepard worked really closely with Rawiri Wharemate, our Māori kaumātua (respected elder), for cultural guidance' One example is that of the tui bird, which appears in the game's first level, titled 'Finding Hope'. 'Tui are synonymous with hope in Māori culture,' Mathijs said. 'If you show people here in the UK, they'll recognise it only as a dark coloured bird. Young people in New Zealand will probably recognise it as a tui, but not many New Zealanders who aren't Māori will know that it's a symbol of hope. Some of that stuff is really subtle but has different meanings to different people.'

One quest involves freeing a tui bird, which symbolises hope within the plot

Mathijs compared this to how people in the UK might recognise the robin, and its significance to winter and Christmastime. 'But if you show a picture of a robin to a New Zealand young person, I'm not sure they'd even be able to name it as a robin. So it's those sorts of references that are quite powerful symbols.'

This representation was worked deep into the game's production, which was made in a co-design process with young people. This collaboration informed the game's plot, which is an important element of the game. 'The story helps explain why the avatar needs to do certain things, and has value in terms of engagement,' Mathijs said. 'The story arc is so important in terms of the motivation of why you'd complete the different levels to see different things happening.'

Serious play

Once players have bought in to the concept and content of the game, there is an additional challenge of keeping the player interested. Looking at gameplay footage of SPARX, however, it appears low on challenge and simple in terms of game mechanics. But this can be a delicate balance when designing a serious game, especially one designed for people with depressive symptoms. 'It's tricky when you're feeling really down,' said Mathijs. 'Anything can feel like a hassle and you could give up.'

The fact remains, this isn't a game on the level of a PlayStation bestseller. 'It's not a commercial game,' said Mathijs. 'It can be a two-edged sword, because young people will be expecting something more sophisticated in terms of graphics and storyline and the skill that's required. This game is very easy to play: there's not really any game skill mastery that you need, you can't really lose, you can't die, and you can't do anything violent; those things I think are part of what makes games really engaging and powerful, and that probably hasn't been fully harnessed in SPARX. But there are all sorts of challenges in those things, too, like do you really want to have a cCBT programme where players can die or fail?'

In a simple action sequence the player zaps gnats that cause gloom

Mathijs noted there's a balance between making an entertaining game and making a clinically useful game. 'There's probably similar tensions between us, from the therapy research side, and the game development company, Metia Interactive. Quite a lot of the characters in the prototype were initially a little sexualised, and in some ways those sort of things might be more entertaining, but they were distracting and not relevant in a serious game. We also have to think about how it will come across to funders and clinicians and parents, so we need to be responsible as well.'

Another concern that people might raise is that gaming could encourage the player to become isolated. 'If they are already not having enough interaction with others,' Mathijs said, 'it could be suggested that you shouldn't have this intervention; you should have an intervention such as having them play sports, so they go outside and interact with young people and that will help them with their depression. I'm not saying that wouldn't be valuable--I'm originally an occupational therapist by background so of course I'm thinking that would be valuable--but it doesn't necessarily mean someone's going to work through their depression and learn the skills to manage that. That's not necessarily going to come from playing sport, unless the person gets some sort of coaching where those skills are drawn out whilst they're doing that activity.'

And what if young people see the game as a sugar-coated pill? This is still, at its core, cCBT in a video game wrapper. Mathijs noted that a lot of cCBT packages are simply online manuals. 'You've had self-help in the form of cassettes, or VHS, or text-based manuals, and SPARX has got that therapy theory and content there, but it's delivered in a game-like format. It's a serious game and it's more than just gamification, because some cCBT will also have gamification elements. SPARX has got a storyline and you've got an avatar that you customise to complete the journey, so in that way I think it's a quite unique contribution.'

Players can customise their avatar

Still, the integration of CBT and gaming content can feel like individual parts. This is indeed a game where you run around and do challenges, but these parts are sandwiched between sections where you speak to a guide character about CBT, which involves a fair bit of traditional reading of text (with a voice-over). Mathijs explained how the game uses 'bicentric frames of reference', composed of egocentric frames of reference ('concerning the details in the information') where the player completes missions in the fantasy world, and exocentric frames of reference ('concerning the big picture') where the guide character explains the CBT content and context of what is happening. The guide character will, for example, provide psychoeducation around depression, recap the previous session's content, teach skills, and explain the real life significance of what the player is doing in the game. It may help a player's identification with the game's content if they approach it from these two perspectives (Lucassen, 2015).

The 'Guide' character teaches the player about thoughts, feelings, and actions – a core foundation of CBT

Could these aspects have been more integrated? Such as exploring behavioural strategies within the actual gameplay? Mathijs thinks this is a challenge. 'Young people, especially those who are more into abstract thinking, will find that a little simplified and maybe patronising. With the age range we're targeting, and we've got a range of abilities as well, if we're not explicit enough, people can miss whole chunks of important content. That's one of the challenges in making it maximally engaging whilst also maximally useful. If the messages are more implied, some users may not be able to gather as much, therapeutically'.

Towards the future

I wondered about the financial viability of developing a program such as SPARX. Sure, it doesn't look like a multi-million-dollar budget game but it doesn't look cheap, either. But if the final product is available for free, how is such a project sustainable? Mathijs said that not only is the development potentially costly, but so is the evaluation and the rollout. 'In commercial games you would get people to pay for the resource and therefore have some sum that could be set aside to re-develop and improve so that you can make the next version. That model doesn't really work in public health because every young person you speak to, you ask 'what would you pay for this,' and they'd say 'I don't want to pay for this,' or 'I don't have the money,' and it just becomes a barrier. There are some real challenges to doing the next version of something if there's no funding set aside for that, and with games developing and progressing as quickly as they do, that makes it really hard.'

SPARX since its inception has continued to grow. In addition to expanding to the young LGBT population with Rainbow SPARX, has also been trialled in Australia with secondary school students, with a version tailored specifically towards stress management. It has also been adapted and translated into Japanese and is being redesigned for Nunavut youth (First Nations young people in Arctic Canada). There is also potential to roll it out on different platforms such as handheld devices.

SPARX is a bold approach to cCBT and you can't argue with the level of engagement it is getting in New Zealand. Accessibility to treatment for mental health conditions is a major problem and solutions like this hint at a promising future for offering therapy to a population who have grown up in a world of technology.

Authored by Sachin Shah

References

Fleming, T.M., Cheek, C., Merry, S.N., Thabrew, H., Bridgman, H., Stasiak, K., Shepherd, M., Perry, Y. and Hetrick, S., 2014. Serious games for the treatment or prevention of depression: a systematic review.

Lucassen, M.F., Merry, S.N., Hatcher, S. and Frampton, C.M., 2015. Rainbow SPARX: A novel approach to addressing depression in sexual minority youth. Cognitive and Behavioral Practice, 22(2), pp.203-216.

Merry, S.N., Stasiak, K., Shepherd, M., Frampton, C., Fleming, T. and Lucassen, M.F., 2012. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ, 344, p.e2598.