Worldwide one in eight children (12.7 %; 18 % of girls; 8 % of boys) become victims of sexual abuse each year . Child sexual abuse (CSA) entails any sexual act (i.e., done for physical or mental sexual gratification of the perpetrator, or experienced by the victim as sexual), inflicted to a child (i.e., below the legal age of adulthood, or developmentally a child), for which full, free, voluntary, and unforced consent was not given (i.e., due to lack of ability, or no true consent), and that occurs in the context of a relationship of power, a position of inequality, or exploitation of vulnerability . Experiencing sexual abuse in childhood or adolescence has drastic and long-term consequences, ranging from a higher risk of a range of psychiatric disorders, drug abuse, relationship problems, sexual difficulties, health problems, later abuse of one’s own child , and increased risk of premature mortality in middle adulthood . Symptoms can occur directly following the abuse, but victims can also remain asymptomatic (estimated up to 40 %) . The most common disorder in young victims of sexual abuse is post-traumatic stress disorder (PTSD) , and child victims referred for therapy experienced high levels of PTSD symptoms . In addition, symptomatology often uniquely related to CSA is sexualized behavior, such as sexual preoccupation or boundary problems .
However, early treatment of victims of child sexual abuse experiencing mental health symptoms appears to be effective in reducing the negative consequences of CSA [8, 9]. Therapies including cognitive-behavioral components (CBT) are the most often used and recommended forms of psychotherapy for CSA victims experiencing psychiatric symptoms [10,11,12,13]. Yet, CBT relies heavily on abstract thinking about one’s cognitions and detailed verbal narration of one’s experiences. These tasks might be particularly difficult for children who have limited verbal capacities or a lack of vocabulary to describe the sexual and intimate acts they were part of .
To increase applicability of CBT with children and adolescents, researchers suggested the use of content that is tailored to the developmental needs of young clients and to emphasize elements of play [14, 15]. Originating from these ideas, serious games (i.e., interactive media that is developed for other purposes than entertainment) have increasingly been incorporated in the context of psychotherapy in the last 10 years . A systematic review concluded that serious games are effective both as a stand-alone intervention or as a tool used in addition to psychotherapy for a wide range of disorders .
However, there appear to be no serious games yet that could be used specifically in the treatment of young CSA victims. Therefore, the aim of this study was to conduct an exploratory evaluation among therapists of a newly developed serious game, called Vil Du?! , that helps children open up about sexual abuse experiences.
Use of serious games in psychotherapy for children
The last decade research, as well as clinical practice, has shown an increasing interest in the use of serious games in psychotherapy for adults and children [16, 18]. This interest is not surprising considering that serious games are highly congruent with children’s experience and involvement with the digital world . In addition, the use of games in psychotherapy fits with recommendations that psychotherapy for children should provide an engaging, client-centered experience . Researchers have suggested that serious games “can be used as a ‘third party in the room’, helping to make the therapeutic process less difficult for adolescents by taking some of the emphasis off direct face-to-face conversations” (21; p. 2937-8). Two reviews summarized the evidence for the effectiveness of serious games in psychotherapy [16, 18]. The authors concluded that serious games are mostly built on CBT and target a wide range of problems in children and adolescents including attention-deficit hyperactivity disorder (ADHD), autism, anxiety, developmental coordination disorder, impaired social-emotional and communication skills, cyberbullying, impulse regulation, and dyslexia. Both reviews concluded that serious games had a positive impact on the learning of skills and strategies, as well as on alleviating emotional symptoms and stress. In addition, the vast majority of children and adolescents reported high motivation to use serious games, as well as satisfaction with the use of serious games, as part of therapy.
Serious games used with children and adolescents in treatment for CSA
Surprisingly, there are hardly any serious games that are developed for use in the context of CSA. The games that have been developed focus primarily on prevention [22,23,24]. One example is Orbit, a CSA prevention computer game targeted at 8- to 10-year-old children . The goal of this adventure game is for the player to do everything they can to help character Sammy that has suffered from sexual abuse. During several mini-games children learn about recognizing CSA, perpetrator tactics, barriers to telling, building a healthy self-concept, and the importance of trusted adults who they can turn to. Researchers currently evaluate the effects of Orbit on children’s knowledge of CSA and how to respond in such situations. In addition, two unpublished master theses describe the development of prototype serious games aimed at helping children to disclose CSA experiences [22, 24]. Pharshy developed a prototype story-telling game in which children can create new stories about their own experiences, or edit existing stories, by using images, drawings, text, and self-created avatars . Parents or caregivers could monitor the child’s stories for possible CSA experiences. Andersson developed a tool for use in a therapy context . This prototype contained different scenes and storylines that therapists could show and play out with children, which could spark conversation about the different (sexual) abuse-related situations children might find themselves in.
The serious game Vil Du?! (Danish for ‘Do you want to [talk about …]?!’) appears to be the first digital game that is being used in a treatment context with child and adolescent CSA victims. Vil Du?! is a non-verbal communication game in which children can show the therapist what happened to them. In the game, which resembles a ‘dress-up game’, both therapist and child operate a self-chosen character, each on their own tablet. The tablets are synchronized to each other, so actions performed on the one screen are also visible on the other, enabling digital interaction between therapist and child. Both players can perform various actions to the other character, by clicking (e.g., undress) or dragging icons (e.g., mouth, hand, penis, buttocks) over the character’s body. Each player can express their boundaries, or pause/stop the game by pressing a Time-Out button. While playing, the therapist can probe the child to talk about its experiences, thoughts, and feelings. The goal of the game was to give children a voice without the need to talk and to put children in charge of creating their own story, normative structure, and values associated to love, sex, and romance.
Components of cognitive-behavioral therapy for which Vil Du?! might be used
As CBT is most often used in the treatment of CSA victims we will evaluate therapists’ use of Vil Du?! within this context. Although many different forms of CBT can be identified in the literature on CSA treatment (e.g., trauma-focused CBT, game-based CBT, group CBT) several common components can be identified [15, 25,26,27] for which Vil Du?! might be used. A first important component in most forms of CBT is psycho-education about sexuality. Through psycho-education children learn to describe private parts and to identify appropriate and inappropriate touches. This vocabulary can facilitate discussion of children’s CSA experiences later on in the therapy process. In addition, learning vocabulary related to sexuality can also be considered a first step in gradual exposure to the child’s traumatic sexual experiences. Furthermore, psycho-education can enhance future safety of children by teaching them skills to recognize risks and provide them with the language to tell others about future sexual transgressions. Generally, therapists use (anatomical) dolls, pictures, and role play for psycho-education about sexuality [15, 28]. Similarly, the icons of the private parts in Vil Du?! might be used for psycho-education about private parts. In addition, therapists and clients might act out role plays with the characters in Vil Du?! in which the therapist uses the icons to perform (appropriate and inappropriate) actions on the client’s character.
Another component is trauma-narration and processing of the sexual abuse experience(s). In order to create and process a narrative of the CSA experiences the therapist invites the child step-by-step to provide increasingly more detailed information about the sexual abuse experiences, as well as associated thoughts, feelings, and behavior. The goal of trauma-narration is to gradually expose children to traumatic memories until children can share their experiences without becoming overwhelmed by negative emotions. The child can create such a narrative orally, in writing, with pictures or with dolls . Similar to doll-play, children might share the story of what happened to them by performing actions on the characters in Vil Du?!.
The trauma-narration process is a gradual process. During the creation of a narrative clients are gradually exposed to trauma reminders. This can help children to master traumatic responses to abuse-related memories, thoughts, and/or feelings. Gradual exposure can for example be done by reading a (fictional/hypothetical) story about CSA or by the therapist reading back parts of the child’s narrative in later sessions. Another way to achieve gradual exposure of children to traumatic memories that might otherwise be avoided is to encourage children to engage in play that realistically depicts their traumatic experiences . Vil Du?! contains explicit icons for the private parts as well as the option to undress the character, which make it possible for children to realistically act out their experiences. In addition, the Time-Out button might be used by client’s to experience control over the exposure to traumatic memories during narrative development sessions .
A third component that focuses on enhancing future safety of children is teaching self-protection skills. In this context, role plays and hypothetical sexual transgressive situations are often used with the child to practice with saying no, with communicating personal boundaries, and with recognizing intuitive feelings and thoughts that signal imminent danger [15, 31]. The perceived realism of role play is an important predictor of the utility of role plays in interventions . Compared to regular role play, virtual sexual role plays were perceived as more realistic  and more effective in learning self-protection skills (i.e., assertive refusal) in threatening sexual situations . In addition, role playing with avatars in a virtual environment (i.e., Second Life) was associated with improvements in psychiatric skills (e.g., management of emotions), expression of less anxiety and more enjoyment than role-playing face to face . Vil Du?! contains male and female characters of different ages which could be used for virtual role plays between therapist and client. The Time-Out button in Vil Du?! might be relevant for the client to express personal boundaries during these role plays.
Although Vil Du?! might be a valuable tool for therapy, a practice manual is not yet developed. A practice manual is essential to foster the adoption of this new tool in clinical practice and to train therapists in the use of this new tool [36, 37]. When a practice manual is developed in a research context and is subsequently introduced to practice this might lead to resistance and criticism by clinicians . Amongst others, the so-called research-to-practice-gap may originate from a lack of applicability of a manual or tool to the diverse and complex clinical context [36, 38]. A manual or tool should thus fit within this complex clinical context. Therefore, manuals can be best developed in close collaboration with therapists. This ensures that their needs are met and the gap between research and practice is bridged . In addition, therapists’ evaluations and experiences of working with a new tool or intervention may stimulate the development of a treatment manual as they can discover innovative ways of working with clients .
To reduce the research-to-practice gap, we included therapists in the development phase of the user manual by examining whether and how therapists use Vil Du?! with several evidence-based CBT components. This procedure will ensure that the end product is as useful and relevant as possible for clinical practice. Another way to bridge the research-to-practice gap is to conduct qualitative research in the context of psychotherapy . Most importantly, because qualitative methods are well suited to providing an understanding of the individual experience of therapists and clients, which would bring research much closer to the complex and individual context of clinical practice.
This mixed-methods study therefore aims to answer the following research question: How can a serious game designed for helping children open up about sexual abuse experiences be incorporated in psychotherapy for CSA? More specifically, how was Vil Du?! used for specific CBT components (components of CBT treatment models, e.g., psycho-education about sexuality, trauma-narration and processing of CSA experiences, teaching self-protection skills)? With which types of clients Vil Du?! was used, and for which reasons therapists used Vil Du?!
By answering these questions, this study can increase our knowledge on which treatment components for CSA victims are relevant in a serious gaming context. Moreover, the project’s results will be incorporated in a practice manual which sets the stage for further evaluation research on the effectiveness of incorporating serious games, and specifically Vil Du?!, in psychotherapy for young CSA victims with mental health issues. Finally, this research also contributes to the broader literature on the implementation of serious games in psychotherapy for children and adolescents.