Keywords

1 Introduction

In recent years, due to the rapid progress of technology, people have invested a lot of energy to keep up with the pace of society, which has exerted increased psychological pressure on university students who are about to enter society. According to statistics, 42.3% of university students have mild or moderate depression, accompanied by other mental illnesses such as bipolar disorder and schizophrenia [1]. However, due to lack of awareness of the disease or fear of facing their own psychological problems, the psychological sub-health problems of university students are often not treated in time. Furthermore, if the patient is not diagnosed with a mental illness, the doctor will not choose to intervene with medication. Although there are many treatments to alleviate depression, such as behavioral cognitive treatment, they need to be completed under the guidance of professionals. Therefore, art therapy, combined with medical treatment, has become an effective method to improve university students’ mental health, by addressing their psychological problems, increase contact with society, and improve their biological clock through serious gameplay without the intervention of others [2].

2 Literature Review

The essence of “art therapy” is “analysis” and “motivation”. The specific method is to freely paint the patient, and then freely associate the picture. (Naumburg 1930) Art therapy is an auxiliary psychotherapy that allows patients to reasonably vent their subconscious content without disturbing their defenses. (EdithKramer 1930) Because in creative behavior (art creation), conflicts are re-experienced, resolved, and integrated, (Rubin 1984) it also facilitates emotional development, intellectual development, and creative expression. (Miralevvik 1983). Creativity is important to human development. (Winnicott 1991) Writing journals, including quick sketches or graffiti, are art treatments that benefit the patient’s expression of the inner world. (Pennebaker, Mayne, and Francis 1997) Using artistic creation to distract attention can trigger positive emotions. (Dalebroux, Goldstein and Winner 2008) Art therapy interventions most effectively alleviate negative emotional states when art therapy interventions require structured tasks that lead to specific outcomes or target states (Kimport and Robbins 2012)

Serious games provide a rich learning environment where users can choose their own choices to enhance their motivation (Morris et al. 2013). The richness of serious games also provides an opportunity to explore, because more powerful and long-term exploration of stimuli can be described as complex (Berlyne 1966). Another advantage of serious games is that they can be viewed as continuous assessments, giving players the opportunity to demonstrate what they have learned (Morris et al. 2013). Serious games enhance learning motivation, effort and participation, thus improving learning outcomes (Garneli, Giannakos and Chorianopoulos 2017; Guillén-Nieto and Aleson-Carbonell 2012; Wrzesien and Raya 2010). The same is true in the medical field (Boeker, Andel, Vach and Frankenschmidt 2013; Diehl et al. 2013; Hannig, Özman, Jonas and Spreckelsen 2012; Lagro et al. 2014; Sliney and Murphy 2008; Stanley and Latimer 2011).

Art therapy is considered to be an effective means of relieving depression and has been used by many clinicians in clinical treatment [3]. Although there are many existing studies on how to treat depression in an artistic way, this study is based on serious game and art therapy mitigation methods for groups of university students with tendencies for depression, and their mental state usually does not be considered that doctoral and drug interventions are needed, so many times the condition deteriorates when it cannot be alleviated. Serious games tend to have an impact on people’s subconscious, therefore games are increasingly used in medicine and education, [3] especially in disease intervention programs, to become a tool to solve social and health problems. This study integrates art therapy into serious games, explores how to combine games with art, makes the target group more acceptable and allows university students to perform step-by-step psychotherapy.

3 Method

The purpose of this study was to help mentally sub-healthy university students to alleviate negative emotions through art therapy based on serious games. This study uses theoretical and analytical physiological data to explore the inclusion of art therapy theory and medical treatment frameworks in serious games to achieve the goal of slowing down negative emotions of mentally sub-healthy university students. (as shown in Fig. 1). This study focused on the combination of art therapy and serious games for the relief of negative emotions in mentally sub-health students. This study took a quantitative approach. In view of the vast space for development in this field, more quantitative indicators will be studied in the future to determine the research results, which will give more straightforward conclusions for future research.

Fig. 1.
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Frame of the experiment

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3.1 Settings

The subjects of this study are university students’ in Shanghai. The authors first used the SDS (Depression Self-Assessment Scale) to screen out suitable subjects (score between 50 and 58, 50 or less for mild or no depression, 59 and upper for major depression). After a brief interview, the participants selected the appropriate subjects based on criteria that included the recent state of life and repression, the status of playing games or using electronic products, and whether they had a certain interest in art. After that, the classification test of depression tendency was conducted again. Accompanied by a professional psychiatrist, the experiment used the self-rating scale of the university student MMPI to conduct further suppression state analysis, test the mental health degree in the near future, and conduct experimental intervention for the population in the high D (depression) category. The plan consisted of two steps: (1) The art materials were prepared experimentally, and the multi-channel physiological instrument and skin sensor were worn and opened during the game experiment by filling the color with a certain visual comfort or painting the relevant theme. The duration of the treatment was 60–90 min, and the physiological indicators of the patients during the intervention were collected. (2) After two weeks of experimental intervention, after a period of experiment, the subjects were asked to fill in the MMPI scale again, and the number of the scale was observed to determine the psychological state after the intervention.

Since the SDS is a very basic measure of the mental state, it can only judge a basic depression tendency and cannot provide a clear classification of the disease, such as whether the patient is depressed or schizophrenic. Therefore, in order to ensure the final effect, the MMPI scale was used to ensure that the effect of the intervention was based on the numerical fluctuation of D (depression), which excluded the experiment from interfering with other types of mental illness.

The serious game in this experiment is divided into three stages. (as shown in Fig. 2). In the first stage, the experimenter will give the proposition of “self-portrait” [4], allowing the patient to have a clear understanding of the existence of the self, and admit themselves. In the second stage, the experiment was based on the illustrations in the famous illustration book “Secret Garden” [5] to match the visual comfort of the illustrations for the patient to paint, while the experimenter provides a pleasant color. In the third stage, the experiment will give the participants the opportunity to self-paint, create their own inner real thoughts, and make themselves more intuitive to face and build life [6, 7].

Fig. 2.
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Three stages of serious game

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This study will produce a “change theory”: a serious game centered on art therapy that can help mentally sub-healthy university students alleviate negative emotions and improve their motivation in the face of depression. This “change theory” can be widely used by schools and society to help university students: (1) acquire artistic creation skills, (2) improve physical and mental health, and (3) improve self-awareness.

3.2 Recruitment

In the experiment, SDS (Depression Self-Assessment Scale) was published on the Internet. A total of 466 university students’ depression status data were collected. A total of 65 students with a depression score of 50–58 were selected, and emails were contacted one by one. It was finalized that 33 university students conducted the study (regardless of attendance). During the course of the experiment, all undergraduates were told in advance that they would wear a multi-channel physiology instrument, a skin sensor, and they all emphasized their willingness to participate voluntarily and to keep the process of the experiment confidential. This experiment ensures that data acquisition is non-mandatory, available, and respects the preferences expressed by university students. If a withdrawal occurs in the middle of the course, the willingness of the participants will be respected. During the experiment, all participants were allowed to record. After the end of the experiment, the author immediately recommended mental health consultation and exquisite gifts to the participants to express their gratitude. The data was collected from June to December 2018. Table 1 is the information of participants.

Table 1. Information of participants
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3.3 Measures

Screening out the target subjects through the SDS, first semi-structured interviews, the interview content: (1) What has made you feel depressed recently? (2) Have you been interested in artistic creation, especially painting? Have you been exposed to painting before? Describe the feelings of painting and the feelings after completing a piece of work. You can also describe the content of the painting. (3) Do you like to play games? What type of games do you usually play? (4) Are you willing to participate in the experiment? Then, participants were told to wear and turn on the multi-channel physiological instrument and skin sensor during the game experiment. The experiment process was recorded, and the experimental results and dialogue were kept strictly confidential.

After the experiment, a brief semi-structured interview was conducted again. The interview contents were: (1) Self-thinking in the process of artistic creation, (2) Suggestions for improvement of this serious game. (3) A brief discussion of the depression of university student conditions and ways of self-remission, and (4) Participants were asked if they would continue to play games related to this kind of art therapy.

The semi-structured interviews before and after the experiment added a basis for theoretical derivation, and more powerful analysis of the effect of art therapy based on serious games, in relieving university students’ depressed emotions, as well as its advantages and disadvantages.

At the same time, during the experiment, the experimenter provided painting tools and proposition and non-propositional painting game titles, and obtained quantitative intervention results through the physiological values ​​of the subjects during the test. Finally, by analyzing the physiological index fluctuations of all the subjects and the MMPI scale records after the end of all experiments, the quantitative analysis of the experiments was carried out, and the rational experimental conclusions were obtained.

3.4 Data Collection and Analysis

There were 33 participants in this trial, 3 of whom were absent from the second MMPI test, and 2 were considered invalid data as the L (lie) value was too high. Therefore, a total of 28 (n = 28) valid records were collected for comparison.

Skin Electrical Value (SC\GSR).

The experiment uses the method of comparing the coefficient of variation (CV). CV has no dimension, so that objective comparisons can be made. CV represents the degree of dispersion of the values ​​during the intervention and can directly reflect the effects of the intervention. After that, the T test was used to compare the coefficient of variation between the experimental group and the control group during the intervention period.

The null hypothesis: in the art therapy intervention based on serious games, the experimental group’s skin electrical value will not change more than the control group.

Alternative hypothesis: in the art therapy intervention based on serious games, the skin electrical value of the experimental group will be higher than that of the control group.

As shown in Table 2, by performing the T-test, the intervention period, the t value = 17.58, p < 0.001, df = 27, and in the case of the Sig. of 0.05, the null hypothesis was rejected. That is, in terms of skin electrical value, there was a significant difference between the experimental group (M = 0.1511) and the control group (M = 0.0404), which showed that the coefficient of variation of the skin electrical value of the experimental group was greater than that of the control group.

Table 2. T-test result of SC\GSR
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Blood Pressure Variability (BPV).

The null hypothesis: in the art therapy intervention based on serious games, the blood pressure variability of the experimental group will not be greater than that of the control group.

Alternative hypothesis: In the art therapy intervention based on serious games, the blood pressure variability of the experimental group will be higher than that of the control group.

As shown in Table 3, by performing the T-test, t value = 0.125, p > 0.05 (p = 0.901) is obtained, and in the case of degree of freedom 27, and significance greater than 0.05, the null hypothesis is supported. That is to say, under the art therapy intervention based on serious games, the blood pressure variability of the experimental group is not greater than that of the control group, which is demonstrated by the fact that there is no significant difference in blood pressure variability between the two interventions.

Table 3. T-test result of BPV
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Heart Rate.

The null hypothesis: in the art therapy intervention based on serious games, the heart rate of the experimental group is not greater than that of the control group.

Alternative hypothesis: in the art therapy intervention based on serious games, the heart rate of the experimental group will be higher than that of the control group.

As shown in Table 4, by performing T-test, t value = −0.716, p > 0.05 (p = 0.480), and in the case of degree of freedom 28 and significance greater than 0.05, the null hypothesis is supported. That is to say, under the art therapy intervention based on serious games, the heart rate of the experimental group is not greater than that of the control group, and the specific rate is that there is no significant difference in the central rate of the intervention process.

Table 4. T-test result of HR
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MMPI Personality Test.

At the end of the experiment, one month later, the subjects conducted another MMPI personality test. The results showed that 65% of the subjects with depression tendency had a significant decrease in D (depression) value, and only 5.56% of the participants D (depression) values rose and were not willing to disclose the reason. Subjects with a significant decrease in D (depression) values ​​also showed a slight decrease in other concomitant mental illness values, and there was no significant increase in any values.

The null hypothesis: in art therapy intervention based on serious games, the MMPI difference before and after the intervention of the experimental group will not be greater than that of the control group.

Alternative hypothesis: in the art therapy intervention based on serious games, the MMPI difference of the experimental group will be higher than that of the control group.

As shown in Table 5, the change of value difference of the MMPI scale D (depression) between the experimental group and the control group before and after the experiment. By performing the T-test, t value = 8.446, p < 0.001, df = 54, in the degree of sig. >0.05, the null hypothesis is rejected. That is, there is a significant difference between the control group and the experimental group before and after the MMPI intervention. The specific performance is that the D (depression) value of the MMPI had a greater decrease than that of the control group after the intervention in the experimental group.

Table 5. T-test result of MMPI
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4 Found

According to the data analysis in the above table, the university students with repression tend to have a higher pre-skin value; upon intervention, the skin electrical value is obviously declining, which proves that the intervention is effective, that is, the serious game with art therapy as the core has relieved the effect of depression. However, for depression-prone university students, the heartbeat before and during the intervention did not show significant differences from the control group. Because university students with repression are more likely to be immersed in their own fantasy world, they can keep their sympathetic nerves in good balance during the period of artistic intervention, so that their breathing slows down and muscles relax. The skin resistance increased and the final skin electrical value showed a downward trend [8]. However, for the heart rate, depression differs from anxiety. It shows that the heartbeat is not much different from ordinary people. After the test, it is concluded that it is impossible to judge whether the intervention is effective through heart rhythm changes.

In the re-interview after the trial, more than half of the university students said that their moods had improved to some extent, and they had found interesting developments, and their negative thoughts had subsided. The above situation proves that long-term use of art intervention can alleviate the symptoms of university students with depression.

5 Discussion

According to experiments and interviews, many university students use art or art-related hobbies as a tool to cope with psychological challenges, and can alleviate depression when performing art or related hobbies. According to interviews with some university students with regards to art, we found that art can give hints to people’s psychology and produce certain self-protection functions.

5.1 Advantages of Art Therapy

In the experiment of artistic intervention, the subjects used their own familiarity with the color of security to create a graphic with visual compressibility in a quiet environment [9,10,11]. In this process, the subject’s vision will gradually relax and the mood will be more comfortable. It is particularly noteworthy that one of the interviewees mentioned that after the completion of the artistic creation, people will have gained a sense of satisfaction and accomplishment. For him, art is a positive righteous thought. In the world of creation, you can give yourself a role in what you can’t do in life. Many of the participants said that they experienced different degrees of harm during their childhood and growth, leading to their current repressive mood. For example, one participant described his emotions as unstable after he lost his father at the age of 15. After that, he used painting to portray the family and his father, allowing his father to be reborn in his fantasy world, after which his depressive symptoms improved [12].

In the subsequent two weeks of experiments, the experiment was conducted to allow the subjects to freely play and engage in artistic creation. In the process, participants immersed themselves in their own world in an unconscious situation [13], and record their thoughts and expectations of their hearts. When they are alone, talk to this mysterious character and play games. In the face of setbacks, they can also gain strength from mysterious characters in fictional places [14]. For example, Carl Jung’s psychological friend is a dwarf. This dwarf satisfies his safety needs and spiritual support to a certain extent, and is the god in his heart [15].

5.2 Advantages of Serious Games

The aim of this experiment was to combine serious games and art therapy. Under the care of professional psychiatrists, university students may encounter (1) inability to persist for a long time to relieve self-depression, and (2) problems such as incorrect methods that lead to unsatisfactory treatment results. Therefore, the study used practical and serious games to aid university students to understand how to conduct art therapy step by step. First, the mechanism of serious gameplay in this study was designed [16]. The experiment used a graphic with visual compressibility to allow subjects to test. People divided the graphics into easy-to-compress graphics and not-easy-to-compress graphics. For people who are upset, it is easy to be more annoyed if they are in an environment that is not easy to visually compress graphics. According to the characteristics of this kind of graphics, the experiment also paid special attention to the compressibility of the graphics. Compressible graphics layout rules, that is, less things, positional rules and less content that the brain needs to deal with. Predictability is also a factor. The predictability of the movement of things will make people feel a sense of control and reduce their psychological burden. Finally, graphical objects are more common, that is, easy to find matching models and provide a little more sense of security and familiarity that can make people relax. Images that are easy to compress exert less pressure on the information processing part of the brain, and the image that is not easy to compress has the opposite effect, which will create processing pressure and make people feel depressed and potentially panic [17,18,19,20].

Secondly, the serious game in this study allows patients to receive treatment with interest regularly. Conducting interesting experiments and explorations, can enhancing insight, improving self-image, and broadening perspectives [21]. In the first week, the content of the treatment was a “self-portrait” task, which did not require a high level of painting, and was used to mainly give the subjects a deeper understanding of themselves. People in a depressed state are more likely to despise themselves and are not confident in themselves. At the same time as the painting, the patient can be self-affirmed: even if there is a defect, there is always a merit worthy of pride. The second stage of coloring is to cultivate the color perception of the patient. If they don’t have the ability to paint their own appearance, coloring is also a viable art creation, and patients can choose interesting black and white lines to increase their interest. The third stage is the stage of self-creation. During the process, the artistic level of university students will be improved. Self-creation allows patients to draw a psychological world, create their own safe space, and build confidence, which can lead to more confidence in future treatment.

6 Limitations of Future Research Prospects

As an abstract treatment, art therapy is now becoming an important intervention in addition to medical treatment. Through the combination of art therapy and serious experiments, this experiment can make appropriate interventions for university students with higher depression tendency, and can be used and re-created in the future game industry and the medical electronics field [22]. However, although the experiment selected different university students to do a lot of data testing to draw conclusions, there were some limitations. First of all, this experiment was not a long-term follow-up type. It is impossible to estimate whether there are other events in the daily life of participants that alleviate the depressed symptoms of the subjects. Second, this study is not applicable to all mentally sub-healthy university students. Only those students who have some interest in art can effectively influence the intervention of the experiment and help this experiment study the meaning and effect of artistic creation on this group of people. For those who have no artistic interest, the experiment cannot guarantee the effect of their intervention. Third, a small number of subjects have a tendency to other mental illnesses other than depression, and cannot prove their role in the intervention process.

It is worth noting that although this experiment uses painting to represent artistic creation, in future practice, sculpture, crafts, music, cooking and other artistic methods can be used to influence people with different interests.

In future research, a more subdivided approach should be considered for comparative analysis of subjects with different levels of depression and subjects with other mental illness tendencies. Studying the courage of artistic creation for different marginalized groups will lay a more solid foundation for future clinical medicine and serious game research.

7 Summary

This study shows that art therapy based on serious games has a certain relief effect on university students with depression. The study also emphasizes the need for art to be more self-protective and to promote mental health. When performing artistic creation, university students can build their own psychological space, relieve visual stress and gain self-affirmation, as well as gaining a sense of accomplishment in artistic creation in the discovery. Although people with depression tendency cannot be attributed to depression, their mental state is also worthy of research and attention, hoping to self-resolve before the deterioration. Therefore, in future research, more in-depth interventions and research are required to make the serious game mechanism more effective in alleviating the depressive state of university students.