Gamification of Cognitive Behavioral Therapy Homework: Therapist Concept Mapping Approach

Greater homework adherence in cognitive behavioral therapy (CBT) is associated with positive treatment outcomes. However, the problems emerging from CBT homework use are common and affect adherence. In recent years, gamification has been explored to increase intervention adherence, but not yet in relation specifically to homework assignments.

In this study, the aim was to gain a better understanding of obstacles to CBT homework and the use of gamification to overcome these.

Concept mapping, a method to organize related information visually, was used in this study. For the 1-day face-to-face concept mapping session, 7 therapists (32 to 55 y, 6 females) participated and generated items based on 2 focal questions of interest. The generated items were grouped on perceived similarity, and each individual item was rated on (1) severity and difficulty (focal question 1) and (2) importance, acceptance by therapist, and acceptance by patient (focal question 2). The item groups on perceived similarity were inserted into computer software. Based on multidimensional scaling and hierarchical cluster analyses, item clusters were generated by the computer software and were presented to the therapists. The therapists were asked for their preference for the number of items a cluster should contain.

Through brainstorming, the therapists collectively generated a list of 29 possible reasons for not doing homework by patients. In the same manner, a list of 38 game design elements that could help patients make CBT homework was generated. External factors (eg, no time due to crisis situations) and lack of motivation (eg, not aspiring to a therapy goal) were perceived as the most important reasons for patients not to do homework. External and symptoms-unrelated internal factors were considered by therapists as the most difficult for patients to change for improved homework adherence. The game design elements, facilitation, and rewards were rated as most important to help patients do homework. These elements were also seen as most accepted by therapists.

Facilitation of doing homework and rewards seem to have the potential to tackle some of the external factors and lack of motivation to make CBT homework that patients could have. Conclusions were limited by the small number of participating therapists. Future research is needed on the effects of specific game design elements, the number of these elements, their combinations, and patients' preferences.