Serious Games for Serious Pain: Development and Initial Testing of a Cognitive Behavioral Therapy Game for Patients With Advanced Cancer Pain

Abstract

Purpose: Cancer-related pain is prevalent among people with advanced cancer. To improve accessibility and engagement with pain-cognitive behavioral therapy (pain-CBT), we developed and tested a serious game hosted within a mobile health intervention that delivers pain-CBT and pharmacologic support. The game focuses on teaching and practicing cognitive restructuring (CR), a central pain-CBT intervention component.

Methods: The pain-CBT game was developed through partnerships with commercial and academic game developers, graphic designers, clinical experts, and patients. Patients with metastatic cancer and pain participated in iterative, semistructured interviews. They described their experience playing each level and reflected on relevance, clarity, usability, and potential changes. Content codes captured patients' suggestions and informed game refinements.

Results: The final game includes five levels that prompt players to distinguish between adaptive and maladaptive thoughts that are pain- and cancer-specific. The levels vary in objective (eg, hiking and sledding), interaction type (eg, dragging and tapping), and mode of feedback (eg, audio and animation). Fourteen participants reviewed the game. Patients appreciated the pain- and cancer-specific thought examples, with a few noting that the thoughts made them feel less alone. Many stated that the game was fun, relatable, and an engaging distraction. Others noted that the game provided helpful CR practice and prompted reflection. For example, one 40-year-old woman said the game "brings [a thought] to the forefront so you can acknowledge it, and then maybe you could let it go or… do something about it."

Conclusion: Patients coping with cancer pain found the CR game helpful, enjoyable, and satisfactory. Serious games have the potential to increase engagement while facilitating learning and rehearsal of psychological skills for pain. Future testing will evaluate the efficacy of this serious game.

Figure 1.. Screen shots of behavioral pain-CBT game (five levels included) that focus on learning and practicing CR specific to the cancer pain experience

NOTE: Level 1: Meditation Under an Open Sky: The first level is designed to introduce players to the game’s mechanics and therapeutic context. Set against a calming backdrop of an open sky, players encounter thought clouds representing their inner thoughts. The objective is to recognize and select positive thoughts, fostering a practice of mindfulness and CR. Level 2: Sledding Down a Mountain: Players navigate a character sledding down a snowy mountain. They encounter clouds with thoughts and need to select to keep or let go of each respective thought. Level 3: Climbing a Mountain: Players climb a mountain, a metaphor for overcoming challenges through a positive mindset. As they ascend, they encounter and sort through a mix of thoughts, continuing to practice CR in a more challenging environment. Level 4: In the Park with Balloons: This level introduces a new character in a park, surrounded by balloons (thoughts). The patient selects a balloon with a thought and must choose to ‘pop’ the negative ones, reinforcing the practice of discarding maladaptive thoughts, or select to ‘keep’ the positive thoughts. Level 5: Fishing for Relaxation: Set by a peaceful lake, players ‘fish’ for thoughts, deciding which to keep and which to release. This activity, often associated with relaxation and mindfulness, offers a reflective space for players to consolidate the CR skills they’ve developed.