OVERVIEW
“Bugs Don’t Have HIPAA” is a game for a group of 3-5 young/new adults designed to teach skills from Cognitive Behavioral Therapy (CBT), a theory of psychotherapy that tries to improve emotional regulation by challenging negative self-talk.
Players step into the role of therapists who are treating bug patients. Each player has notes on their patients that they can use to help patients reframe and challenge their negative thoughts.
As we move through our day, our brains generate a stream of thoughts in reaction to the situations we encounter. The overwhelming majority of our thoughts are Automatic Negative Thoughts, or ANTs! Most ANTs are Cognitive Distortions: warped perceptions of reality that are inaccurate, unhelpful, and overly self-critical. If left unchecked, ANTs can be distressing and overwhelming. By challenging our cognitive distortions, we can change our thinking patterns over time and decrease how frequently we experience ANTs.
This game is designed to produce aesthetics of fellowship, role-play, and expression. After playing this game, players will be able to identify cognitive distortions in their own thoughts, and apply the CBT thought model to care for their mental health in their daily lives.
We want to teach and reinforce CBT concepts outside of therapy. We hope to make CBT concepts more approachable and provide a context that is distinct from their personal lives for people to practice addressing cognitive distortions.
We were inspired by games like:
- We’re not really strangers
- Finch – bird journaling app
- Wellbeing Bingo – a therapy tool for encouraging self care
- (The Secret Ingredient) is Love – solo journaling RPG
As we designed this game, we wanted to avoid:
- Causing harm rather than help through poor teaching
- Making a game that is dry and clinical rather than fun i.e. memorization game
- Making our players uncomfortable.
RULES
Materials
- Bug cards
- Situation cards
- ANT cards
- Cognitive Distortion cards
- Therapy Note cards
- Play mat
- Cognitive Distortion reference sheets
- Point Tokens
Setup
- Each player should pick one Bug card.
- Separately shuffle each deck of cards.
- Deal each player 5 Therapy Note cards.
- Give each player a set of Cognitive Distortion cards
- Place the play mat and all card decks within reach of all players
Play
- Each round, one player is a bug patient seeking treatment and other players are therapists trying to treat them. The player who most recently saw an ant will be the patient for the first round.
- To start, the patient draws one Situation card and one ANT card.
- The patient places their Bug card on the “patient” space on the play mat, the Situation card on the “Here’s what happened” space, and the ANT card on the “Here’s what I’m thinking right now” space
- Therapist players should look at the Therapy Note cards in their hand and the current patient’s situation and ANT. Each player selects their Therapy Note card that best challenges the patient’s ANT and places it face down in front of them.
- Players should also select the Cognitive Distortion card that they think the patient’s ANT is an example of and place it face down in front of them.
- Once all therapists have played their Therapy Note card and their Cognitive Distortion card, therapists will present their Therapy Note and Cognitive Distortion to the patient. Starting with the therapist to the patient’s left, each therapist reveals their Therapy Note card and their cognitive distortion card, then gives a 2-3 sentence explanation for why their Therapy Note best challenges the patient’s ANT. Therapists do not yet explain why their chosen Cognitive Distortion card fits the ANT.
- Once all therapists have presented their Therapy Notes, the patient selects their favorite. The therapist who played it gets 2 point tokens.
- Additionally, determine which cognitive distortion was played the most. The players who played that cognitive distortion i.e. the players who played the majority cognitive distortion each get 1 point token.
- If there is a tie, each side gets 30 seconds to argue for their chosen cognitive distortion, and the patient selects a winner.
- The first player to collect 15 point tokens wins!
ASSESSMENT GOALS
In our first meeting, we narrowed down which CBT topic to teach in our game: Cognitive Distortions, and ANTs. Our goal for our player is to leave the game having improved at detecting and classifying the various cognitive distortions, and challenging them, with different, healthier thoughts – hopefully in their own lives, as well as within our make-believe scenarios.
We created surveys for a hypothetical larger scale study. In the pre survey, we ask relevant demographic and background questions to gain insights into other questions, and quiz the participant a bit about the Cognitive Distortions. We created a follow-up survey meant to be taken one week after the study, in order to assess retention of learning material, as well as adaptation of desired behaviors (identifying Cognitive Distortions in everyday life.)
To that end, we let our participants/players each choose a small souvenir, a handout with references to the distortions, plus a silly bug character, to use as reference later in life. We then sent out the follow-up survey after one day, because of our timeline.
Below: players choose a handout with the bug character they’ve grown attached to, and debrief.
Examples of questions we asked our participants in our surveys include:
- Have they been to therapy before?
- How familiar are they with Cognitive Distortions?
- How many times in the past week have they been significantly bothered by negative thoughts and moods?
- How many times in the last week have they detected cognitive distortions in their thoughts?
- And how many times noticing it has helped them work through it.
- We included various quiz questions challenging participants to identify a cognitive distortion based on an unhealthy thought, which varied with each of the three surveys.
LEARNING RESULTS
During our final playtest, we heard comments such as, “I’m actually learning,” a good sign. Compared to the pre-survey, players, after having played one game, scored better on the three quiz questions at the end of the survey.
Most notably, before playing, 3 of 4 players reported not detecting, or being unsure of detecting, cognitive distortions in their own thoughts recently. After playing one game, 100% of players responded that they have detected cognitive distortions in their own thoughts recently. After playing the game, the percentage of “yes” responses to the question “Has knowledge of cognitive distortions helped you dispel negative thoughts and moods recently?” had already increased. Players who could previously not name any cognitive distortions pre-playtest, could list a few post-playtest.
Of the players who filled out the follow-up survey one day after the playest, all of them reported having detected cognitive distortions in their thoughts recently, and finding the knowledge useful is treating negative thoughts and moods.
OTHER THOUGHTS ON OUR OUTCOMES
Some players expressed discomfort when filling out our survey, and may have felt that it was prying. Mental health is a sensitive topic, especially for those who are unused to talking about it regularly. It also occurred to us that a player could believe that our game is not intended for them, because they do not identify with any psychiatric disability. The reality is that CBT, and knowledge of the cognitive distortions can benefit anyone.
In order to create behavior change, we need to ensure that our players view CBT skills as positive and desirable, as well as positively viewed by peers. In the same vein of thought, the stigma that surrounds mental-health treatments could create resistance to learn and adopt CBT skills.
In the future, our game must ensure that players understand that CBT concepts can help anybody, and are positive skills, no matter how they identify. We can accomplish this with flavor text in our instructions, on the box, etc.
That creates another challenge for a game that aims to teach CBT skills: dispelling stigma. If we were to measure our success at that in the future, we could ask whether the players are considering trying therapy or reading about it before and after the game, especially for those who reported never having been to therapy.
One more challenge to address in future design iterations: the frequent usages of condolences by players during gameplay. “At least,” or “silver lining” statements are known to be ineffective ways to address negative thoughts and moods, and create a barrier to true empathy – they do not resolve negative thoughts, but distract from them. (I am very sure you find citations for this.) In the future we would aim to design gameplay that challenges players to truly reframe and resolve the unhealthy thoughts of our bugs.
ITERATION HISTORY
Our first iteration of the game was actually two different games; our group had split off to ideate and then evaluated our ideas together through an internal team playtest. The two basic premises were “Apples to Apples with bug therapy” and “Charades for cognitive distortions”. Following our internal playtest, we decided to combine the versions to create what would become our final game. We took the Apples to Apples style game play with ANT cards and Positive Thought Cards, and added the scenario and roleplaying elements of the charades game to create Bugs Without HIPAA’s first official game.
We then tested this game in four playtests, three in class and one outside of it.
PLAYTEST #1: In class, a group of five college-age classmates.
PLAYTEST #2: A group of three roommates and long-time friends, aged 22-23.
PLAYTEST #3: A group of 4 college-aged classmates. 1 student playing for the second time
PLAYTEST #4: A group of 4 college-aged students. 1 student playing for the second time.
For Playtest #1, our testers played the simplest version of our game. There were three decks: the Character/Situation cards, the ANT Cards, and the Positive thought cards. Each player also received a confidential folder with 13 kinds of cognitive distortions written on the interior. Each turn, one player would be the Judging Therapist, and select a random character card from the deck and present the situation to the group. They would also pick two ANT cards from their hand to play with the character card. All other players would play a heart card face down, and when ready, flip them over simultaneously. Each player got to say a sentence to justify their choice before the judge selected their favorite and awarded the winning player with the character card.
Since we combined two versions of the game rather suddenly, there were some slight disconnects in aspects of the game. Some cards were very scientifically accurate bug facts, while some were more vague and anthropomorphic. Surprisingly, we found that players absolutely adored the theme. All noted that they enjoyed the bug theme, as well as the mix of human-like and bug-like activities because “the misaligned situations created a lot of humor”. However, we also heard testers note that while they had fun, they were unsure how much they actually learned about cognitive behavioral therapy or automatic negative thoughts. They also noted that the game had slightly odd pacing, since the card selection phase was often dead silent, and sometimes long in contrast to the short, loud and boisterous justification phase. Finally, they noted they didn’t know what to do with the cognitive distortions on the folder, since it was confusing and unclear what they were for.
After this game, we decided to try a more subtle approach to addressing this feedback. We added an explanation about cognitive distortions to the rules and encouraged players to use them in their justifications to try and make it more educational. The second set of playtesters also received our first Learning Goal Assessment iteration, a simple and short pre-quiz and post-quiz.
We found that while the second group of playtesters still enjoyed the game, they still weren’t learning much through the game. There was very minimal change in how much they knew about CBT and ANTs before and after, so we decided to brainstorm apart and come up with a fresh new direction for our game.
Version 3 of Bugs Without HIPAA incorporated secrecy and deception in the gameplay. The Judging character now hid the ANT card from the therapists, and when players played their Positive Thought Cards, the judge would select the one that most addressed their hidden ANT card. After three rounds, each player would guess the kind of cognitive distortion the ANT card was based on the winning positive thought cards. Players continued to enjoy the theme and delight of the game, but found it a little too challenging given their lack of experience in the subject. Players reflected feeling unsure of how to categorize distortions, and some frustration with the fact that some thoughts might fall into multiple categories. The judging therapist also felt like they had trouble picking positive thoughts that addressed the ANT since they weren’t sure what the ‘right’ answer was. Despite this, there was more knowledge gained through this version than others, as players said they actually thought about the distortions and understood them a little more through gameplay.
The final version of our game was a return to form with an added sub-round of guessing cognitive distortions along with playing the ANT cards. As we reflected on all our previous playtests, we decided to go backwards in iterations because we wanted to bring back the high level of engagement our players had with the first two versions. We also created another version to test, based on a debate mechanic between two players instead of judging across all players, because we saw how players enjoyed interacting with each other throughout the playtests. Across all tests, players would excitedly speak out of turn or interrupt each other with passion about their positive thought card or doubts about the other player’s explanations, and we wanted to foster more opportunities for this kind of interaction.
After playtesting both versions in class, we saw that the Apples to Apples style final version had more engagement, more learning, and more positive feedback from players than the debate version. Our pre and post assessments showed notable improvement across player understanding, with almost all players going from “I don’t know” to being able to categorize ANTS into cognitive distortions. Though players still found some aspects confusing (the first person perspective of the Therapy Note cards, the point system, how long rounds should be), we felt this version best achieved our aesthetic, fun, and learning goals for this project.
