Sokoon

International Journal of Gaming and Computer-Mediated Simulations
Volume 15 • Issue 1
Sokoon:
A Gamification-Based Cognitive Behavioral
Therapy Application – An Application
for Depression, Stress, and Anxiety
Nourhan A. Amer, Mansoura University, Egypt
Samaa Mohammed Shohieb, Mansoura Univerfsity, Egypt*
Waleed M. Eladrosy, Mansoura University, Egypt
Hazem Mokhtar Elbakry, Mansoura University, Egypt
Samir M. Abd Elrazek, Mansoura University, Egypt
ABSTRACT
The World Health Organization (WHO) estimates that depression, anxiety, and stress disorders
(DASDs) are prevalent worldwide, resulting in the loss of 13 million years of life and trillions of
dollars of economic loss annually. Mobile-based health (M-health) interventions can employ mental
health interventions such as cognitive behavioral therapy (CBT) for adolescents worldwide. Arab
youth who struggle with DASDs do not tend to engage in mental therapies, but gamification and
modularization have the potential to boost their appeal. The authors have selected effective CBT
interventions for DASDs, adapted them to digital interactive formats, and integrated gamification
concepts. An Arabic mobile application, Sokoon, which means relaxation and relief, may encourage
Arab users to practice the required CBT skills for mild-to-moderate DASDs. A pilot study was
conducted to evaluate the effectiveness of Sokoon App in a small group of adults who had signs of
aDASDs. Sokoon was practicable, well-received by users, and had a positive impact on participants’
feelings of anxiety and sadness.
Keywords
Anxiety, C-CBT, Cognitive Behavioral Therapy, DASD, Depression, Game-Based Therapy, Gamification,
Hexad Theory, M-Health, Stress
1. INTRODUCTION
University students and teenagers frequently suffer from depression and other mental health problems
such as anxiety and stress, which affect their academic performance (Richardson et al., 2012; Riglin et
al., 2014; Steptoe et al., 2007). A systematic analysis revealed that the weighted mean prevalence rate
of depressive disorders was 30.6% among university students from several countries, including those
in the Middle East, North America, East Asia, and the European Union (Ibrahim et al., 2013). Many
DOI: 10.4018/IJGCMS.324098 *Corresponding Author

This article published as an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and production in any medium,
provided the author of the original work and original publication source are properly credited.
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studies (Sachs & Malaney, 2002; Moussavi et al., 2007; Lorant et al., 2007) have found that adverse
effects that result from depression, anxiety, and stress disorders (DASDs) can result in the loss of
approximately 13 million years of life annually and trillions of dollars of economic loss. However, the
development of computerized cognitive behavioral therapy (C-CBT) interventions, which was driven
by the necessity to address the unmet needs associated with traditional psychological therapies that
are costly and difficult for many populations to access as well as rapidly increasing access to Internet-
enabled devices and cheaper software development (Khazaal et al., 2018), has increased during the past
decade. Although gaming has become an integral part of everyday teen life, individuals have trouble
adapting to and handling its persuasive nature during puberty (Brooks et al., 2015). Recently, games
have been employed in many fields such as different therapies and education (Shohieb et al., 2020;
Hady & Shohieb, 2020; Kokol et al., 2020; Shohieb, 2018). Gamification refers to the use of gaming
elements and mechanics in non-gaming contexts. Because mobile-based health (M-Health) interventions
are simple to integrate into users’ daily lives, designing a treatment based on this platform may be
advantageous because this may lead to increased involvement with C-CBT interventions. Research
on game-based cognitive behavioral therapy (CBT) interventions has revealed its potential benefits
for mild-to-moderate DASDs symptoms)Khazaal et al., 2015; Leutwyler et al., 2015; Tárrega et al.,
2015; Merry et al., 2012). The use of gamification in community health education may appeal to the
public and entice gamers to access health promotion materials during leisure time, according to a meta-
analytical review (Cheng & Ebrahimi, 2023) that examined the effectiveness of gamified interventions
in promoting mental health. The gamified app performs better than the non-gamified app in terms of
self-reported resilience, other well-being indicators, and anxiety reduction (Litvin et al., 2020). There is
proof that gamification can be successful in encouraging good health outcomes (Fitzgerald & Ratcliffe,
2019) including lowering depression and anxiety symptoms (Damaševičius et al., 2023; Sinha, 2021).
This fosters the improvement of psychological issues or the development of mental wellness in people
on all sides. However, the most familiar gamified apps do not include all the CBT skills required for
DASDs interventions (Dias et al., 2018; Shohieb, 2019; Coyele et al., 2017; Dias et al., 2020; Miloff
et al, 2015; Christie et al., 2019; Brezinka, 2012; Addepally & Purkayastha, 2017). There is only one
study (Jamaludin et al., 2021) that applied hexad theory with elements of gamification for depression
diagnosis, sokoon applied them for treatment. Furthermore, the available DASDs mobile-based CBT
interventions have been designed in non-Arabic languages and for other cultures. Consequently, to
generalize, such applications are not suitable for most Arab users. In this study, the full design of an
Arabic gamified CBT intervention, namely, Sokoon, for mild-to-moderate DASDs that accommodates
teenagers and young Arab individuals are examined. The main objective of Sokoon is to provide Arab
young people with mild-to-moderate DASDs symptoms with the opportunity to decrease negative
mood and enhance positive mood, life satisfaction, coping skills, and health-related quality of life. It is
believed this may lead to enhanced productivity and success for young Arabs, which may subsequently
directly increase the national economy. Concerning the gamification user type’s classification and Hexad
theory, Sokoon can be customized and personalized (Andrzej Marczewski, 2018). This is likely lead to
the maximization of user motivation, engagement, and consequent usefulness.
2. C-CBT STATE OF THE ART
DASDs have similar symptoms; thus, various treatments such as CBT are utilized to treat DASDs
(Rodriguez, 2015; Holland, 2018; Bruno, 2009). Computerized health interventions have increased
in popularity because of many factors, including the ease with which information can be exchanged
via the Internet and the fact that computers can be mobile, small, and readily accessible (Victoria
Barbosa, 2015; Tavares et al., 2015). However, studies have revealed that using fully automated
self-help systems is often correlated with low levels of adherence (Andrews & Williams, 2015);
therefore, it is imperative that systems developed as psychotherapeutic intervention tools must take
user adherence into account to strengthen remote support and bonding.
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Based on the latest trends, gamification has become a strategy employed to engage and motivate
users in many areas, including health, education, and business applications (Brown et al., 2016; Dias
et al., 2018; Shohieb, 2019).
Patient adherence and engagement are of paramount importance to ensure treatment is effective.
Therefore, gamification can be employed as a technique to promote patient adherence and engagement
in DASDs therapy. Accordingly, a systematic mapping study (Dias et al., 2018) was employed to select
related work. A search string, which was created from the terms depression and gamification as well
as their synonyms, was inserted into eight scientific repositories, including PubMed Central, Journal
of Medical Internet Research, Google Scholar, IEEE Xplore Digital Library, ACM Digital Library,
Springer Library, Wiley, and Science Direct. The following question was asked: How is gamification
being used to support mental health? Studies that focused on the use of C-CBT to support DASDs
activities that resulted from this systematic mapping study were added to this study. These studies
concerning the following eight CBT applications for DASDs are listed in Table 1:
1. gNATs (Coyle et al., 2017)

2. IAware (Dias et al., 2020)
3. The challenger app (Miloff et al., 2015)
4. Quest - Te -Whitianga (Christie et al., 2019)
5. Treasure Hunt (Brezinka, 2012)
6. MoodTrainer (Addepally & Purkayastha, 2017)
7. Sparx (Yokomitsu et al., 2020)
8. SmartCAT (Pramana et al., 2018)
Table 1. A systematic mapping study for related work
The Quest - Te Treasure MoodTrainer SmartCAT

gNATs IAware Sparax
Challenger Whitianga Hunt ((Addepally & (Pramana
APP (Coyle et al., (Dias et al., (Yokomitsu
App (Miloff (Christie et (Brezinka, Purkayastha, et al.,
2017) 2020) et al., 2020)
et al., 2015) al., 2019) 2012) 2017)) 2018)
Year 2017 2019 2015 2019 2014 2017 2020 2018
Depression ✓ ✓  ✓ ✓ ✓ ✓ 
Anxiety ✓ ✓ ✓ ✓ ✓ ✓  ✓
Stress        
Gamification  ✓ ✓ ✓   ✓ ✓
Game ✓ ✓ ✓ ✓ ✓  ✓ ✓
Targeted for
children/  N/A N/A ✓ ✓   ✓
youth
Targeted for
✓ N/A N/A   ✓ ✓ 
adolescents
Targeted for
 N/A N/A   ✓  
adults
Mobile
✓ ✓ ✓ ✓  ✓ ✓ ✓
device
Computer
✓    ✓   ✓
device
Location  ✓ ✓   ✓ ✓ ✓
Notification  ✓ ✓   ✓ ✓ ✓
Hint: ✓: Applied, : Not applied
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The eight CBT widely used applications for DASDs, market share, and the features of their
products are summarized in Table 2.
3. THE PROPOSED SYSTEM (SOKOON)
3.1 Sokoon Specifications and Description

In comparison to the eight CBT applications for DASDs, the features of Sokoon have the
following advantages:
• A mobile-based gamified application.

• Supports youth and adolescents with DASDs.
• The following seven CBT intervention skills are standardized for DASDs intervention:
◦◦ Relaxation
◦◦ Gratitude
◦◦ Self-compassion
◦◦ Problem-solving
◦◦ Social skills
◦◦ Behavior activation
◦◦ Cognitive restructuring
In comparison to the available related work, the features of Sokoon are summarized in Table 3.
3.2 The Proposed Interventions in Sokoon for Each CBT Skill

In Sokoon, the user’s customized avatar visits a 3-D world called Sokoon which has seven planets.
Each planet is designed to be the equivalent of a standard treatment session and supports a single
component of a customized, developmentally appropriate CBT intervention for seven skills that should
be provided in the DASDs interventions. Key concepts were illustrated through videos, conversations,
embedded animations, mini-games, and interactive stories. The seven skills and design interventions
in the Sokoon application are listed in Table 4.
A study of Table 4 demonstrates that some of the designed interventions in Sokoon depend
mainly on music and/or voice tones in storytelling, especially in relaxation, gratitude, and self-
compassion. Merging music is already employed in therapy techniques in DASDs. Many studies
(Braun Janzen et al., 2019; Leubner & Hinterberger, 2017; Ray & Götell, 2018; Tang et al.,
Table 2. Local and international CBT applications’ features and market share
The
gNATs IAware Quest - Te Treasure MoodTrainer
Challenger Sprax SmartCAT
(Coyle (Dias Whitianga Hunt ((Addepally &
Characteristics App App (Yokomitsu (Pramana
et al., et al., (Christie et (Brezinka, Purkayastha,
(Miloff et et al., 2020) et al., 2018)
2017) 2020) al., 2019) 2012) 2017))
al., 2015)
English
English and
Language and English English English English English English
French
Spanish
150/
Free
single Free (some 20 $ /mini-
Single License (some Free N/A N/A N/A
user sessions) game
levels)
license
Android Android/ Android/

Platform Compatibility Android Android Android Android / IOS Android
/IOS IOS IOS
Downloads > 10000 >500 >500 >50 >50 >50 >1000 >10
4
Table 3. The features of Sokoon compared to the available related work
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Table 4. The designed interventions in the Sokoon application for each CBT Skill
(Depression/
Stress, or/
CBT Skill The proposed intervention in “Sokoon” application
and Anxiety)
Adequacy
• Interactive activity: swimming in the ocean, getting coins while listening to
Depression
relaxing music. Similarly, there can be a set of different choices like (nature,
1-Relaxation Stress,
space, waterfall…etc.). A voice-over commentary notes can give the listener more
Anxiety
relaxation.
• A gratitude garden in which an avatar touches (tree, flower…etc.) to open a
game with different gratitude phrases. Depression
2-Gratitude
• In addition to gratitude voice or readable notes that can represent the objects/ Anxiety
terms that give the user more gratitude feelings.
Depression
3-Self- • Interactive stories that give the player some morals indirectly. In the middle of
Stress,
Compassion the story, the player answers questions to measure his/her reactions.
Anxiety
• Interactive stories for different problems with the ability for choosing from
4-Problem- Depression,
different choices (positive, negative)
Solving Anxiety
• Problem-solving, puzzle games.
Depression
• Interactive stories with different choices in the story to learn user communication
5-Social Skills Stress,
and debate skills.
Anxiety
6-Behavior • Provide a collection of different activities. Depression,
Activation • Challenges between player and other players (future step). Anxiety
• Provide different selections about different negative topics he feels about
Depression
7-Cognitive (failure-isolation-hopeless…) and practice some relieving actions like bubble
Stress,
Restructuring shooting or balloon hitting.
Anxiety
• Time-based positive words game.
2020) have examined the impact of music-based therapy on depression. The findings revealed
that measures of depression and associated symptoms such as sleep quality and quality of life
had significantly changed from baseline. Furthermore, other studies that mainly explored using
voice tone variation in compassion-based therapy for patients with DASDs (Heriot-Maitland et
al., 2019; Hickey et al., 2017) found the efficiency of utilizing voice tones when communicating
with depressed people.
Each activity in the seven planets in which the users participate has coin rewards. Users can
spend their coins on a main planet to upgrade both their personalized avatar and the planet itself as
well as solve problems in their virtual community on the main planet. This affords much support for
self-compassion, behavioral activations, and problem-solving skills.
At the level of data representation and algorithms, game mechanics are features that comprise a
game’s abstract structure. It is rare to think of a game without picturing the accompanying aesthetics
and game mechanics. Consequently, the feel of the game and users’ positive experience can be created
primarily with the good utilization of suitable visual game mechanics (Laakso, 2019; Chou, 2014;
Deterding et al., 2011). However, gamification dynamics can also be regarded as the fulfillment
of desires. Human beings have a natural drive to be noticed, compete with one another, and attain
success. Game mechanics are tools that can be employed to assist in determining how to move the
action and engage the players (Deterding et al., 2011).
One of the important features of the designed system is to analyze the type of user personality.
Andrzej Marczewski’s Player and User Types Hexad (2018) was employed to analyze such (Figure 1).
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Figure 1. Andrzej Marczewski’s player and user types hexad (2018)
Six different types of users are defined in this model: disruptor, free spirit, achiever, player,
socializer, and philanthropist. RAMP, namely, relatedness, autonomy, mastery, and purpose, reward,
and change (Andrzej Marczewski, 2018), motivates them.
The users’ main characteristics are as follows:
1. Socializers: Networking or relatedness motivates socializers who want to make social connections
and engage with others.
2. Free Spirits: Autonomy and self-expression inspire free spirits who desire to experiment and develop.
3. Achievers: Power and mastery inspire achievers. They want to not only develop their awareness
and evolve as individuals but also search for obstacles to solve.
4. Philanthropists: They are guided by a sense of purpose and meaning. They are willing to give
to others and enrich their lives without expecting anything in return.
5. Players: Rewarding players motivates them. They will do whatever is asked of them in order to
receive incentives from the system. In essence, they are only interested in themselves.
6. Disruptors: They are empowered by the need to improve. They endeavor to change the system in
some way by employing other users, either directly or indirectly, to force positive or negative change.
The authors employed this model in our system to add more levels of personalization and use
suitable gamification techniques in accordance with user character type. This can be done by using a
set of questions during the game to allow the users to express their preferences. The basic gamification
mechanics or dynamics are displayed in Table 5. It includes the basic design items that correspond to
each game mechanic/dynamic explanation and their visual representation in Sokoon. The adequacy of
that mechanic for each user type in relation to Andrzej Marczewski’s Player and User Types Hexad
(2018) for each used mechanic is also listed in Table 5.
4. METHODS AND MATERIALS
4.1 The Starting Point

The main idea is to use computer gamification techniques to treat mild and moderate DASDs. The
techniques include building a set of mini-games, interactive activities, and interactive stories to
empower the patients with self-training. They can also be extended to be part of psychological therapy.
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Table 5. The basic gamification mechanics/dynamics vs. their visual representation in “Sokoon”
Gamification Mechanic or Dynamic, Visually User Type

Design Element in “Sokoon”
Representation Adequacy
Player, Achiever,
Scores, Feedback Units, or other
Indicators (lives or time left) indicating progress Socializer,
feedback
Philanthropist
Socializer, Achiever,
Leaderboards, Status, and Ranks Display of monikers or ranks Indicating progress
player, Disruptor
Philanthropist,
Tasks or Stories that organize character rewards, guide
Narrative, Quests, and Challenges Free spirit, Player,
action, and roles
Achiever,
Disruptor, Free
A customizable and personalized representation of the
Avatars and Voice spirit, Socializer,
player supported voices
Philanthropist, player
Player, achiever,
Levels Increasing difficulty of activities via progress bar
socializer
Points, Badges, and Rewards Visual game tokens or icons indicating achievements Player, Achiever
Achiever, player,
Progression Signifying progress through Milestones in the game
Socializer
Social Engagement and Social Sharing of gameplay and/or progress with social media
Socializer
Networks contacts
Non-lockable Content Content that needs to be explored Free spirit
Collect, Trade, and Share Content that helps the user to share his/her knowledge and
Philanthropist
Knowledge gifting
Content geared specifically toward players who just want
Planned Anarchy Disruptor
to loot all the time
4.2 Research Design

A randomized controlled trial will be conducted to discover the effectiveness of a gamification-
based CBT intervention with advanced techniques applied like Hexad theory and DDA for games
for depression, anxiety, and stress treatment. Participants will complete self-report measures of
depression symptoms Phq-9 and measure of anxiety symptoms GAD-7 after two weeks of using
Sokoon. Assessments of depression, anxiety, and stress will be conducted at baseline and at the end
of the intervention. Data will be collected and analyzed to examine the effects of the intervention on
depression symptoms, motivation, engagement, and treatment satisfaction.
4.2.1 Technical Methods/Approaches

The techniques suggested were to employ gamification tools provided by a Unity (2d/3d) gaming
engine (Download Unity!, 2019) to build several mini-games as well as interactive activities and
stories as an Android mobile application. Unity engine is primarily a cross-platform engine, which
eases the conversion process to other platforms if required such as web, desktop, and IOS.
4.2.2 Behavioral Analysis

Behavioral analysis is a useful technique that enables more user engagement during gameplay. The
most suitable gamification techniques are personalized in relation to the user type classification in
the user profile registration step.
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One of the key concerns in our research was to avoid unbalanced levels of challenges in
gamification activities. Players are likely to experience boredom if activities are too easy. On the
contrary, players may feel upset and anxious if games are too difficult (Figure 2).
To accomplish this, it is necessary to measure the level of the users dynamically in accordance
with their actual performance in runtime and subsequently assess players’ skills to recommend suitable
gamification activities and their degree of difficulty.
4.2.3 Dynamic Difficulty Adjustment (DDA) Techniques

One of the problems in many traditional games is the static difficulty of each level. In many cases,
the game designers predefine the difficulty of the level regardless of the actual performance level
of each player. That can make the game levels either very difficult or too easy for some players.
One way to solve this problem is a technique named Dynamic Difficulty Adjustment (DDA)
(Sepulveda et al., 2019). DDA is one of the primary techniques employed in behavior analysis.
DDA is a technique for automatically adjusting scenarios, parameters, and behaviors in video games
in real-time, based on the player’s skill and preventing boredom (when the game is too easy) or
frustration (when the game is too challenging or too difficult). It can be conducted by comparing
players’ current statistics to the ideal or a reference performance (first-time performance of the
current level). The time duration measure can be used to evaluate players’ results (Sepulveda et
al., 2019) by employing the following equations:
N −Z
Difficulty = (1)
D
Ease = 1 − Difficulty (2)
where:
Figure 2. An illustration of player experience (Sepulveda et al., 2019)
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• Difficulty refers to the current difficulty level of the current user.

• N refers to the performance measure (count of times to repeat) for the current user to perform
an action or activity in a game.
• Z refers to the baseline performance measure (count of times to repeat) for the reference player.
it can be calculated either:
◦◦ For the same player but for the first (Easiest) first level. The first level shall be considered
a baseline of the DDA calculations in that case.
◦◦ Or for the average results of a testing sample of users.
• D refers to the time duration for the current user to perform their action.
• Ease refers to the current level of easiness of the current player.
In the original DDA technique (Sepulveda et al., 2019), if the user performs an action for N of
times in a duration D period of (time, ticks, or other measuring units), with the ideal or reference
value being Z, then using a value set that abides by (0 ≤ (N − Z) ≤ D) will return a normalized value.
If that condition is met, then both Difficulty and Ease will have normalized values ranging from 0 to 1.
So, the first time the player completes the first level in a game, his/her performance is stored as
a Z value. After that, the next time, the player retries playing the same level (or plays the next levels),
the values of N and D are calculated in runtime to dynamically adjust the level. This adjustment
process can be applied in three forms:
1. Between levels: (After the end of one level and before the start of the next level).
2. Periodically within a level: It can be applied periodically during gameplay of levels to
dynamically update level difficulty from time to time with waiting to finish the level. The
frequency of the application of the DDA algorithm, in that case, depends on the level of average
completion time.
3. At checkpoints: This is similar to the 2nd form, but instead of using fixed time units between
DDA re-calculations. It can be applied when a player reaches some locations (checkpoints) at
the level, or when he/she completes a partial sub-task on the way.
Another technique called Reference Player’s Difficulty (RPD) can be used also to dynamically
adjust level difficulty at runtime (Sepulveda et al., 2019). In the PRD technique, the user should play
the first level to measure the initial value of Difficulty with the eq. 3. If the RDP >= 0.5 then the
difficulty will be decreased for the user in the next level otherwise the difficulty will be increased:
S1 − S 2
RDP = (3)
S1
where:
• S1 refer to best score for the first level.

• S2 refer to user’s score for the first level.
Example: If S1=30 and S2=15 then RDP is calculated as follows:
RDP =
Then the difficulty will be decreased in the next level for the user to increase his/her involvement.
The best situation is to reach a value of 0.5 or similar for easiness, thus indicating the proposed
challenge is suitable for the current user.
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A third approach is to evaluate current player performance (Cp) against expected player
performance at that time (Ep[t]). The latter served as our reference point. The Expected player
performance can be either fixed by the game designer according to his estimation of level difficulty,
or it can be based on a statistical analysis of a random sample of test players during the game release
phase. In that approach, the performance of the current player is calculated according to eq. (4):
CP
Performance = (4)
EP[t ]
At first, the initial design uses the default level of difficulty that was found suitable for
the testing sample of users during development. Subsequently, the DDA engine of the system
automatically compares the current player’s performance with the standard (reference) player’s
performance. The system modifies the current level of difficulty following these results. When
the performance value is almost the value of 1, the current level of difficulty is suitable for the
current user’s skills.
Also, the previous techniques can be combined also to give more details about current player
performance. In our proposed project, we plan to use a combination between the first approach
DDA and the third approach. The main steps involved in applying the DDA technique in Sokoon are
presented in Figure 3.
Figure 3. Applying DDA in our proposed system (Design Credits: The research project team) (Please Note: Difficulty refers to
the current difficulty level for the current user. Its normalized value ranges from 0 to 1 . N: refers to the number of times that the
current user performs an action or activity in a game. Z: refers to the ideal number of times of the reference player (default user).
D: refers to the time duration for the current user to perform their action. Ease refers to the current level of easiness of the current
player. Its normalized value ranges from 0 to 1.)
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4.2.4 Analysis of the User’s DASD’s Severity Improvement

The second challenge of the user’s behavioral analysis is to analyze whether the proposed CBT
intervention presented through Sokoon is efficient and analysis of the improvement of the DASD’s
severity after applying the proposed CBT intervention presented. The user’s desire for the next therapy
session is one of the most essential measurements of success for the user’s progress (Boll & www.
rtor.org, 2016). As a result, if the Sokoon’s user is persistent in entering and interacting, it shows that
he/she accepts the intervention. This stage is accomplished by tracking:
• The number of times the user accesses the application.

• The total time the user spends during each activity.
• The score the user achieves.
4.3 Proposed Sokoon System

Seven skills required for the psychological treatment of anxiety and stress are targeted in the proposed
system. As depicted in Figure 4, Sokoon is divided into five main components.
4.3.1 The System Components Include
1. User’s Profile Component represents the user features during their experience. The user features
include the user id, collected points, and levels progress.
2. Personality Hexad Checker applies the theory of the user’s Hexad to determine their personality
type and subsequently selects the appropriate gamification mechanics for the current user.
3. Gamification Engine Component applies the gamification rules based on user activities. This
component is also responsible for rewarding user points in accordance with progress.
4. Behavior Analysis Engine (Based on the DDA algorithm) applies the behavior analysis rules –
introduced in section 4.2.1 - to analyze the user profile and feedback. It subsequently updates the
user profile with the progress that has been achieved after each level. This component is divided
into seven sub-components, which each focus on a specific skill. Those sub-components include:
a. skill 1- sub-component: Relaxation
b. skill 2- sub-component: Gratitude
c. skill 3- sub-component: Self-compassion
d. skill 4- sub-component: Problem-solving
e. skill 5- sub-component: Social skills
Figure 4. Block diagram of Sokoon (Design credits: Authors)
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f. skill 6- sub-component: Behavior activation

g. skill 7- sub-component: Cognitive restructuring
5. Activity Presenter includes interactive graphics and multimedia elements at each level. Those
assets provide an attractive interface and scenarios so that the required therapy can be applied
to the user.
Each of the above skills has a set of practices and interventions experienced by an avatar. The
activity presenter component selects the suitable interventions for each skill. Those intervention(s)
include one or more of the following:
1. Mini game
2. Interactive activity (similar to a tutorial with a set of interactive items)
3. Interactive stories
Some skills also comprise a combination of those techniques. The system encompasses the
sequence of steps depicted in Figure 5. In this flowchart, the main algorithm of Sokoon is presented.
At the start, the system collects basic information and thereafter makes an initial analysis of the
user’s type in accordance with Hexad’s theory (Andrzej Marczewski, 2018). The system displays the
skills list from which the user can select, with customized gamification mechanics according to the
user type classification performed. After selecting a skill, the system monitors user behavior during
Figure 5. General flowchart of the Sokoon (Design credits: Authors)
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gameplay and offers the required awards in accordance with the user’s achievements. If the user
experiences difficult activities as challenging, those activities are marked for a dynamic change of
difficulty to provide the user with additional help. When the user completes the required tasks of a
skill, an analysis is conducted of their behavior and progress. Accordingly, the user profile is updated.
4.4 Design of Sokoon Framework

The first two pages of the application, namely, the login pages, are portrayed in Figures 6 and 7. Users
enter important data such as name and age on the first page. They are also able to choose the avatar
that suits their personality and customize it as they want, which, in turn, has an important role during
Figure 6. The first page of the Sokoon application (login page) (Design credits: The authors)
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Figure 7. The second page of the Sokoon application (The user type test) (Design credits: The authors)
the game. The personality test depicted in Figure 7 enables one to determine the player’s personality
according to Andrzej Marczewski’s Player and User Types Hexad (2018).
As depicted in Figure 8, the first page of the application after the login pages comprises the
seven planets: relaxation, problem-solving, activity, gratitude, self-love, pros, and social skills. The
name of each planet is derived from the name of the skill it discusses. Each planet is a CBT skill that
assists users to enhance their psychological state.
1. Relaxation planet: The planet of relaxation helps users to relax, which is of paramount importance
in DASDs. It comprises a collection of activities such as a simple game in which a player swims
in the sea and collects a light with relaxing music. There is also a collection of videos with
15
Figure 8. The first page in the application after the login pages (Design credits: The authors)
different types of relaxing music and images such as nature, waterfalls, space, and landscapes
from which users can choose. Furthermore, there are breathing exercises to assist users to relax.
2. Activity planet: The activity planet focuses on behavioral activation skills. Players learn the
importance of staying active on this planet and becoming involved in a variety of activities that
can improve mood and well-being. The planet provides a large variety of activities for users that
suit their personalities.
3. Problem-solving planet: Problem-solving solving abilities are taught through a series of
interactive scenarios that are relevant to young people on this planet. The game teaches
basic problem-solving skills such as identifying and defining issues, creating solutions,
16
evaluating options, choosing solutions, implementing the action, and assessing results
(Problem-Solving, n.d.).
4. Gratitude planet: Each time players enter the gratitude planet; they choose something for which
they are grateful. Initially, they select from among a group of choices, including their mother,
friend, father, sister, and brother. Subsequently, once they have chosen what they are grateful for,
this is added to their garden. The planet has a large garden full of trees and roses. Each tree the
user clicks on opens a simple game that allows them to search among a tree’s leaves for things
for which they are grateful such as family, friends, life, and blessings.
5. Self-love planet: The self-love planet is concerned with the self-compassion skills. It encompasses
an interactive story in which players can help others and impart advice to love and encourage
themselves. In another story, players are provided with morals indirectly. In the middle of the
story, players answer questions to measure their reactions.
6. Social skills: On this planet, players are given interactive stories that contain a challenging
dialog and/or negotiation with another character in which a variety of communication skills
are taught. The players, represented by their avatars, make decisions in relation to how to act
in a given situation. Poor decisions result in the relationship becoming tenser and are a source
of conflict. However, positive communication is the key to winning the game and progressing
through the levels.
7. Pros planet: This planet is concerned with cognitive restructuring skills. Every day, the planet
sends a notification to users with positive words. The purpose of some of the games is to help
users to get rid of their negative thoughts. The users break these thoughts, which are in the form
of stones and balloons, by smashing them or piercing them with arrows.
4.5 Implementation and Deployment

The game was developed as an Android mobile application. Although the Unity engine is the used
platform, it is primarily a cross-platform engine. This eases the conversion process to other platforms
if required in the future, including web, desktop, and IOS.
4.6 Validation and Verification Methodology

4.6.1 Aim of Study
The primary purpose of this study is to evaluate the effect of implementing C-CBT based on
gamification to treat mild and moderate DASDs. This includes building a set of mini-games, interactive
activities, and interactive animated stories for patients with DASDs to enable them to engage in self-
training as well as possibly extend this proposed intervention to psychologists.
4.6.2 Experimental Design

A quasi-experimental design will be employed:
1. Settings: The setting will be the Faculty of Computers and Information at Mansoura
University, Egypt.
2. Subjects: Convenience sampling will be employed to select 120 subjects. The Epi InfoTM (2019)
program with a confidence coefficient of 90% was employed to determine the size of the sample:
a. Inclusion Criteria: See below:
i. Population: Adolescents, and young adults between 18-35 years of age who have
been diagnosed with mild-to-moderate DASDs. The Structured Clinical Interview for
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [50] will
be employed to diagnose depression. The Hamilton Depression Rating Scale (HAMD)
scores (Carneiro et al., 2015) will be used to diagnose moderate depression.
17
ii. Intervention: C-CBT via the Arabic mobile application Depression Rating Scales,
Fifth Edition (DSM-5) (Tolentino & Schmidt, 2018) will be used to moderate DASDs
through a series of mini-games and activities that have been customized and personalized
in relation to the Hexad theory’s user type classification.
b. Exclusion Criteria: Adolescents who have delirium, visual, or auditory deficits, spinal
disorder, cognitive impairment, expected short-term mortality, and/or have been admitted
to the hospital following cardiac arrest will be excluded from the study.
3. Data Collection: The PHQ-9 (Kroenke et al., 2001) and GAD-7 (Sousa et al., 2015) tests, which
were given at pre-test and post-test, were among the data gathering tools. The number of sessions
finished, the length of each session, and any technical issues encountered were all collected in-
app. The program must be used by participants for a period of two weeks, and they must be able
to access it from a computer or other internet-connected device.
4. Ethical Considerations: Ethical approval has been obtained from the ethics committee of
the Faculty of Computers and Information, Mansoura University. Informed consent will be
obtained from subjects who are willing to participate in the study. The confidentiality of
the data will be assured.
5. EXPERIMENTS AND RESULTS
5.1 The Experimental Pilot Study

From Mansoura University, given in Table 6, five volunteers (one male and four females) between the
ages of 18 and 35 were chosen. According to the PHQ-9 and GAD-7 tests, all participants reported mild-
to-moderate symptoms of anxiety and depression. The participants had no prior history of mental illness.
The gamification-based cognitive-behavioral treatment program was explained to the participants,
and they were instructed to utilize it for two weeks determined under the guidance of a psychiatrist.
Prior to utilizing the application, participants underwent a pre-test assessment of anxiety and
depression. Participants completed a post-test evaluation after two weeks. Data on participant
involvement, app use, and technical difficulties were also gathered.
The data gathered for the study, including means and standard deviations for the pre-test and post-
test scores, were analyzed using descriptive statistics. Additionally, content analysis was performed
to identify recurring topics in the participant feedback.
5.2 Results
With an average daily usage time of 15 minutes, participants reported good levels of engagement
with the app. Participants were 24.6 years old on average (SD = 6.06). The participants’ anxiety
symptoms decreased from the pretest (M = 10, SD =.7) to the posttest (M = 4.2, SD = 1.5), as did
their depressive symptoms (M = 10, SD = 2.05), posttest (M = 6, SD = 1,7).
Table 6. Participant information
Users Sex Age Depression degree Anxiety degree

User1 F 21 Mild Moderate
User2 M 35 Moderate Moderate
User3 F 21 Moderate Mild
User4 F 21 Mild Moderate
User5 F 25 Moderate Moderate
18
Figure 9. The result of the depression test and anxiety test before and after using Sokoon
5.3 Limitations
Preliminary results indicate that Sokoon is effective in treating mild-to-moderate anxiety and
depression, which indicates that more research should be conducted to obtain the maximum benefit
and best results. The generalizability of the results is constrained by the limited sample size and the
lack of a control group. To corroborate the early findings of this pilot study, further research should
utilize a larger sample size and randomized controlled trial approach.
6. CONCLUSION AND FUTURE WORK
Because a number of young people and adolescents have suffered from DASDs recently, the design of
Sokoon, a mobile application that can be employed as an intervention for Arab youth with DASDs, is
discussed in this paper. In Sokoon, evidence-based C-CBT skills based on gamification are provided.
Gamification plays an important role in promoting participation, commitment to treatment, and
increasing psychological reinforcement. Making use of game mechanics and dynamics such as
points and badges, progress tracking can be accomplished through a series of games, activities, and
animated interactive stories that are personalized for each user. Although Sokoon cannot replace
psychotherapists, the main purpose of the application is to assist patients with DASDs by employing
mobile phones. It is believed that CBT has the potential to significantly improve the availability of
effective psychological therapies for adolescents and young adults. Andrzej Marczewski’s Player
and User Types Hexad (2018) is employed to determine users’ personality types and subsequently,
appropriate game mechanics for each user are adapted. The DDA technique is applied in the designed
mini-games to measure the level of the user dynamically in accordance with their actual performance
collected during the use of the application in comparison to reference data to assess the required skills
and recommend a degree of difficulty for each skill continuously.
Other components of CBT should be considered in future studies. Other CBT skills can be added
to the application, which can also include a section for children who suffer from depression, anxiety,
and/or stress. Furthermore, the application may obtain the geographical location in order to assess
19
certain capabilities to develop various skills. While having access to evidence-based treatment has
several advantages, it may have a negative influence if the application’s usage is extreme and has an
adverse effect on social life. Furthermore, it is possible to include a special section for psychotherapists
so they can monitor patients’ condition and provide important advice and guidance to ensure that the
treatment is completed properly, thus enhancing the application’s value and effectiveness.
CONFLICT OF INTEREST
All authors declare that they have no conflicts of interest.
FUNDING STATEMENTS
N/A
20
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24
APPENDIX
A short test similar to classifying the type of user in a gamified system (Andrzej Marczewski, 2018).
Each question has seven selections with seven scoring for each selection (Strongly agree (3), Agree
(2), Somewhat agree (1), Neither (0), Somewhat disagree (-1), disagree (-2), Strongly disagree (-3)).
1) It makes me happy if I am able to help others

2) I see myself as a rebel.
3) I often let my curiosity guide me.
4) I like to try new things.
5) Rewards are a great way to motivate me
6) I dislike following rules.
7) It is important to me to follow my own path.
8) It is important to me to always carry out my tasks completely
9) The wellbeing of others is important to me.
10) It is important to me to feel like I am part of a community.
11) I like overcoming obstacles.
12) It is difficult for me to let go of a problem before I have found a solution
13) Being independent is important to me.
14) I like helping others to orient themselves in new situations.
15) I enjoy group activities.
16) If the reward is enough I will put in the effort.
17) Return on investment is important to me.
18) I like to question the status quo.
19) Interacting with others is important to me.
20) I like mastering difficult tasks
21) I like competitions where a prize can be won.
22) I like to provoke
23) I like sharing my knowledge.
24) I like being part of a team
25
Samaa Shohieb is an associate professor at the Information Systems department, faculty of Computers and Information
Sciences, Mansoura University, Egypt. She’s interested in Human-computer Interaction integrated with E-society,
Gaming, and Gamification as solutions for diverse users especially those who are with specified capabilities.
Waleed M. Al-Adrousy was born in Maca, KSA in 1982. He is an Egyptian researcher. He received Bsc, Msc and
Phd degrees of computer science from faculty of Computer and Information sciences, Mansoura university in 2004,
2010 and 2015 respectively. He worked as a demonstrator from 2004 to 2010, and as a teaching assistant from
2010 to 2015, and as lecturer from 2015 till present in the faculty of Computer and Information sciences, Mansoura
university. He is interested in several scientific fields like: social network analysis, recommender systems, distributed
systems, game development, 3D modeling, simulation, mobile development, security and software engineering.
Hazem El-Bakry (Mansoura, EGYPT 20-9-1970) received B.Sc. degree in Electronics Engineering, and M.Sc.
in Electrical Communication Engineering from the Faculty of Engineering, Mansoura University - Egypt, in 1992
and 1995 respectively. Dr. El-Bakry received Ph. D degree from University of Aizu-Japan in 2007. Currently,
he is full professor at the Faculty of Computer Science and Information Systems - Mansoura University-Egypt.
His research interests include neural networks, pattern recognition, image processing, biometrics, cooperative
intelligent systems and electronic circuits. In these areas, he has published many papers in major international
journals and refereed international conferences. According to academic measurements, now the total number of
citations for his publications is 4325. The H-index of his publications is 32. Prof. El-Bakry has the United States
Patent No. 20060098887, 2006. Furthermore, he is associate editor for journal of computer science and network
security (IJCSNS) and journal of convergence in information technology (JCIT). In addition, he is a referee for
IEEE Transactions on Signal Processing, Journal of Applied Soft Computing, the International Journal of Machine
Graphics and Vision, the International Journal of Computer Science and Network Security, Enformatika Journals,
WSEAS Journals and many different international conferences organized by IEEE. Moreover, he has been awarded
the Japanese Computer and Communication prize in April 2006 and the best paper prize in two conferences cited
by ACM. He has also been awarded Mansoura university prize for scientific publication in 2010 and 2011. Dr. El-
Bakry has been selected in who Asia 2006 and BIC 100 educators in Africa 2008.
Samir M. Abd Elrazek received the B.Sc. and M.Sc. degrees from the Faculty of Computers and Information,
Mansoura University, Mansoura, Egypt, and the Ph.D. degree, in 2013. He has been an Assistant Professor with
the Information systems Department, Faculty of Computers and Information, Mansoura University. He is interested
in intelligent information systems areas, such as big data, AI, system analytics, intelligent systems, and decision
support systems. He has been working on some research projects in healthcare area, E-learning, and management
information systems. He has authored/coauthored over 30 research publications in peer-reviewed reputed journals,
book chapters, and conference proceedings. His current research interests include data analysis, information
systems, machine learning, and pattern recognition. He has served as a Reviewer for various international journals.
26

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International Journal of Gaming and Computer-Mediated Simulations

DOI: 10.4018/IJGCMS.324098 *Corresponding Author

2. C-CBT STATE OF THE ART

1. gNATs (Coyle et al., 2017)

Table 1. A systematic mapping study for related work

The Quest - Te Treasure MoodTrainer SmartCAT

Year 2017 2019 2015 2019 2014 2017 2020 2018

Hint: ✓: Applied, : Not applied

3. THE PROPOSED SYSTEM (SOKOON)

3.1 Sokoon Specifications and Description

• A mobile-based gamified application.

3.2 The Proposed Interventions in Sokoon for Each CBT Skill

Android Android/ Android/

Table 3. The features of Sokoon compared to the available related work

Figure 1. Andrzej Marczewski’s player and user types hexad (2018)

4. METHODS AND MATERIALS

4.1 The Starting Point

Gamification Mechanic or Dynamic, Visually User Type

4.2 Research Design

4.2.1 Technical Methods/Approaches

4.2.2 Behavioral Analysis

4.2.3 Dynamic Difficulty Adjustment (DDA) Techniques

Ease = 1 − Difficulty (2)

Figure 2. An illustration of player experience (Sepulveda et al., 2019)

• Difficulty refers to the current difficulty level of the current user.

• S1 refer to best score for the first level.

4.2.4 Analysis of the User’s DASD’s Severity Improvement

• The number of times the user accesses the application.

4.3 Proposed Sokoon System

4.3.1 The System Components Include

Figure 4. Block diagram of Sokoon (Design credits: Authors)

f. skill 6- sub-component: Behavior activation

Figure 5. General flowchart of the Sokoon (Design credits: Authors)

4.4 Design of Sokoon Framework

4.5 Implementation and Deployment

4.6 Validation and Verification Methodology

4.6.2 Experimental Design

5. EXPERIMENTS AND RESULTS

5.1 The Experimental Pilot Study

Table 6. Participant information

Users Sex Age Depression degree Anxiety degree

6. CONCLUSION AND FUTURE WORK

All authors declare that they have no conflicts of interest.

Epi InfoTM. (2019). Epi. https://www.cdc.gov/epiinfo/index.html

1) It makes me happy if I am able to help others

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