A Proposal For a Therapeutic Conversation Simulation

Background / Need:

New approaches to evidence-based preventative treatments for depression among young people are needed.  E-learning is effective in lab settings, where adherence is achieved via extrinsic incentives such as financial payment and social pressure, but have disappointingly low adherence in the field.  Talk therapy has higher adherence but could be improved, and has unsolved barriers to access (cost, convenience) for most teens.  New therapeutic experiences must be both engaging and effective in treating teen depression are needed.

Therapeutic Aims

A core concept of CBT is that thoughts, feelings, and behaviors form a triangle of interrelation. CBT therapy teaches us to:

  • be aware that thoughts and feelings affect behavior, and vice versa.
  • acknowledge that inappropriate thoughts and feelings are common
  • ignore inappropriate thoughts and feelings,
  • choose behaviors that reduce bad thoughts and feelings


Here we propose a novel interactive experience of the ‘thoughts-feelings-actions’ concept from Cognitive Behavioral Therapy.

Specifically, we propose a novel dialog system design can achieve the therapeutic aims while providing a more entertaining conversation experience with computer-controlled characters.  This ‘win-win’ design approach is key to achieving adherence.

Existing Approaches to Conversation in Video Games

Video games typically embody a narrative, and require players to converse with game-controlled characters.  Users experience 3 steps: 1) hear a prompt line from the game’s character. 2) choose a response from a short list. 3)  the game’s character responds with a line and loads another list of choices.  This structure is called a ‘dialog tree’:

This system is a poor approximation of a realistic conversation, as illustrated in this parody:


Our novel dialog selection mechanic that combines the typical RPG dialog system with the thoughts-feelings-actions model from Cognitive Behavioral theory.

  • During conversation with characters, player’s internal thoughts and feelings endlessly stream by
  • At any time, player selects one, to convert it to action (say it out loud).
  • Player learns to acknowledge and ignore inappropriate thoughts, which float away offscreen
  • If player does not act, the game has default responses with timeouts.

Our first interactive prototype demonstrates the basic idea.

Our design addresses the specific aims of CBT:

  • be aware that thoughts and feelings affect behavior, and vice versa –>
  • By watching thought balloons float by, they practice ignoring inappropriate thoughts and feelings.
  • Players realize that thoughts have no impact on game outcome. It’s common and normal to have inappropriate thoughts and feelings
  • Players often choose ‘wrong’ answers in character dialogs, because it’s entertaining to see bad outcomes. They will then “undo” the choice to progress in the game.  This playful pattern reinforces that the winning strategy is to ignore inappropriate thoughts and feelings

Next steps: Test and Revise

The prototype above is a first step in an iterative design process.  The next step is to test the prototype with players, note the success and failure with the aims.