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ReBoot:
Reducing Stress and Anxiety Through Interactive Technology
Christopher J Barrile
Canisius College

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Abstract
Recent breakthroughs in interactive technologies have revolutionized the way we
maintain our personal health. Numerous research studies have been conducted on how
interactive technologies affect the brain, as well as their effectiveness as an aid in maintaining a
healthy lifestyle. However, research and developments on maintaining mental health via
technologies is lacking. Literature has revealed the cognitive benefits of using interactive
technologies such as video games, as well as the implications of using said technologies in the
counseling environment. This study explores the effectiveness of a mobile application
specifically designed to reduce stress and anxiety.
Keywords
Interactive Technology, technology in counseling, video game, psychology, mental health apps,
gaming psychotherapy

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ReBoot:
Reducing Stress and Anxiety Through Interactive Technology
Introduction
The use of mobile interactive technology is currently revolutionizing how we look at our
personal health. With the development of applications or “Apps,” hardware and software
developers have been able to design elaborate programs to help monitor our personal health.
With the ever-increasing number of smartphone users, these applications can be made available
instantly to millions of people worldwide. These same applications that work to keep us
physically fit also have the potential to be carried over into the realm of mental health. Efforts
should be made to improve the whole person, not just the physical body.
Technology, whether we see it or not, impacts our lives daily on a rather large scale.
Around 85% of American adults own a cellphone (Smith, 2012), while around 45% own a
smartphone (Raine, 2012). For the purpose of this study, “Smartphone” will be defined as any
cellphone capable of running mobile applications and access to the Internet. With nearly half of
all cell phone users owning a smart phone, the capabilities of these devices has increased as well.
Individuals can control their lights, thermostat, door locks, television, gaming consoles, all from
a device small enough to fit in your pocket. Technology is becoming engrained deeply in our
way of life; it would only make sense that such technologies should be used to better us as well.
On September 19, 2014 Apple Inc. released the iPhone 6 and 6 plus. These devices
revealed the numerous personal care possibilities of modern smartphones. The interior contents
of the device include a sophisticated gyroscope, pedometer and altimeter. The combined efforts
of these three technologies allow the phone to detect when a person is walking, running,
climbing stairs, tracking distance and calories burned. In addition to this, the phones camera

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includes an infrared sensor capable of accurately measuring heart rate. Combine these pieces of
hardware with an easy to use software application and you have given the average smart phone
user a way to monitor their personal health in ways never before possible outside of the medical
setting. Though through all these advances, there still appears to be little headway gained in the
realm of mental health, although the literature points to the mental benefits of using interactive
technologies.
Literature Review Methods
Literature on the subject of interactive mental health technologies is a new and
developing, therefore little evidence-based research exists on using technology to improve
mental health. The search procedures used for this study included databases accessed via
Canisius College (Ebsco, ProQuest, Sage), the Entertainment Software Rating Board and the
Pew Research Center. Internet searches and credible online news sources have also been used
for information and social statistics data.
Literature Review
Utilizing Things We Already Do
One of the most common activities that utilize interactive technology is gaming. The first
video game came into existence on an oscilloscope screen back in 1958 (Kent, 2001). It was
nothing more than a few controllable pixels you played a game of “tennis” with. Since then,
gaming has boomed into a multi-billion-dollar industry. According to the Entertainment
Software Rating Board (2015), 67% of households in the United States play video games
(consoles or PC). It should be noted that this study failed to mention mobile gaming which has
became a multi-million dollar industry on it’s own.

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What is it about the gaming experience that draws in millions of people annually?
Furthermore, how can we utilize the power of video games to show their potential psychological
value and clinical application? First we have to distinguish when games are beneficial and when
they are detrimental.
Specific video games can be designed for use in mental health care. The repeatability
aspect of video games, as compared with other media forms, is useful in delivering manual-based
interventions such as those involved in cognitive–behavioral therapy (USAB, Holzinger, &
Gesellschaft, 2007).
Sharek and Wiebe (2014) conducted a study that measured individuals’ engagement in a
video game via cognitive and affective dimensions. The study discussed what is known as flow
and cognitive load theory. This theory provides insight on measuring gamer engagement during
game play. By analyzing the interactions between skill and task challenge, the development of
this real-time measurement of engagement provides a more precise diagnostic method for
designing challenging, yet cognitively engaging, tasks.
Figure 1
Figure 1 depicts the model for flow theory. If a game has both little skill and challenge,
the player will fall into the boredom condition, lacking interest and desire to play. If the game is

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too challenging and requires too much skill, the player will find themselves frustrated, possibly
leading to higher levels of stress and anxiety, which we are working to avoid. When a game is
equally challenging and levelly skilled, the player will feel engaged and immersed within the
game, and so they will continue to play, engaging in beneficial cognitive stimulation.
A total of 169 people were recruited to engage in a game where you must match 3D cube
structures to fall into their proper slot by moving them across the board. Participants are given
the option to check a time clock in order to see if the minimum amount of time has passed before
moving on. The hypothesis were that individuals who are bored or frustrated will be more likely
to check the time clock more than those who are experiencing “flow.”
Those in the Frustration condition performed the worst and produced the most errors
(falling off the game map) compared with those in flow and boredom conditions. The Boredom
condition created the fewest errors (the study noted this was most likely due to boredom/lack of
trying).
78% of participants were from the United States, 58% were female, and 42% were male
(M age = 30.79, SD = 10.22). Thirty-three percent (evenly distributed between conditions)
reported that they had previous experience with a similar type of puzzle game. Assuming that a
game being used to reduce stress and anxiety is designed with “flow” in mind, the next logical
step forward would be to determine if video games posses the ability to reduce stress and
anxiety.
Clinical Applications
In 2006, a study was conducted to look at the potential benefits in using video games to
reduce anxiety in children during pre-operation procedures (Patel, 2006). In a randomized,

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prospective study of 112 children aged 4–12 years undergoing outpatient surgery, anxiety was
assessed after being admitted for treatment and again at mask induction of anesthesia, using the
modified Yale Preoperative Anxiety Scale (mYPAS). Postoperative behavior changes were
assessed with the Post-Hospital Behavior Questionnaire (PHBQ). Patients were randomly
assigned to three groups: parent presence (PP), PP and a hand held video game (VG), and PP +
0.5 mgÆkg 1 oral midazolam, a benzodiazepine that induces feelings of sleepiness and
relaxation. The midazolam group is labeled (M) and is given the medication twenty minutes
prior to entering the operating room. The study ultimately concluded that children whom were
given the video game, displayed lower levels of anxiety when compared to the other groups. This
is based upon their measured heart rate, as well as the PHBQ that was completed following the
procedure.
Continuing with the topic of anxiety, the Association for Psychological Science was one
of the few studies to focus on the specific use of a smartphone application to reduce anxiety.
McCarthy (2014) engaged participants in a game focused on attention-bias modification training

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(ABMT). This training teaches individuals to ignore threatening stimulus, and to instead, focus
on neutral or positive stimulus. 75 participants who scored high on the intake anxiety assessment
were asked to follow two virtual characters around on the screen, tracing their paths as quickly
and accurately as possible. After playing the game, the participants were asked to give a short
speech to the researchers while being recorded on video (hoping to provoke anxiety with the
presence of the camera). The videos qualitatively revealed that participants who played the
ABMT-based game showed less nervous behavior and speech during their talk and reported less
negative feelings afterward than those in the placebo group. Much in sync with the ideas of this
proposal, McCarthy (2014) believes that apps could eventually be developed to assist in the
treatment for mental health disorders, such as anxiety management, depression or substance
addiction.
Technology During a Counseling Session
In 2014, a group of second professional year Doctor of Pharmacy students enrolled in a
pharmacy practice laboratory. Students were randomly assigned patients in whom they would
work through a counseling session where they discuss the usage of their medication. Students
were randomly assigned to either a portable tablet or a desktop computer group. During patient
counseling, students using the portable tablet were given access to information on the
medication, diagrams, and online database access. The desktop computer group was allowed to
utilize only the hand written notes of the student. Surveys were developed and distributed to
students and instructors following each counseling session.

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Table 1 lists a selection of survey questions and their response percentage. In relation to
maintaining focus on the client, presenting important information and overall counselor
confidence, the students whom worked with the tablet felt more comfortable and prepared than
their desktop peers. Seeing the active potential of interactive technologies in both a clinical and
counseling setting, how may we move these functions into the realm of psychotherapy?
Technology and Psychotherapy
Interactive technologies have a variety of applications in the psychotherapy environment.
However, stigma from the media and public eye has reduced the use of these technologies in a
therapeutic environment (Ceranoglu, 2010). Though even with the lack of extensive research
and public acceptance, the first video game specifically designed to support cognitive behavioral
therapy was recently released (Brezinka, 2007, 2008). The game offers uses engaging homework
assignments that vary depending upon what the client and counselor are working on together.
Games to enhance social skills training for children with developmental disorders also
exist (Mineo, Ziegler, Gill, & Salkin, 2009). These programs feature virtual environments where
the player controls an “avatar,” or character within this environment using a controller, mouse, or
a gamepad. Through interactions with the virtual environment, the player may rehearse learned
social and problem-solving skills.

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Summary And Conclusions
Even with the limitations and lack of extensive research on these technologies, evidence
points to the mentally therapeutic possibilities of video games and other interactive applications.
When appropriate design and function of these technologies is taken into consideration,
researchers have the ability to determine which types of games, activities, and information are
beneficial and which hinder cognitive and emotional well being of clients. While past studies
have gathered small samples on their effectiveness, it would seem that larger long-term studies
and data collection are lacking in this area. Providing a medium for a large number of individuals
to access and manage their own mental health can move this field forward by providing larger
samples, as well as gathering real time data on the activities of users, and receiving feedback on
how this medium can grow and evolve.
The Problem
Modern advances in interactive technologies have made a large impact on our ability to
maintain personal health. While great time and effort have been spent focusing on our physical
human health, there appears to be a lack in applications associated with maintaining both
cognitive and emotional mental health.
My Hypothesis
A mobile smartphone/tablet application designed to incorporate proven stress and anxiety
reduction activities will show that users are going to be more likely to have reduced levels of
stress and anxiety when compared to those enrolled in counseling who are not using the
application.

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Methods
Design
The application called “ReBoot” will record demographical information on each
individual user so that they may be sorted accordingly via age group and sex. When the user
opens the application, they are asked to rate their mood via a 1-10 scale. Based upon their
answer, they are guided towards a variety of activities the application offers. Once the user
completes or chooses to switch activities, they are asked to rate their mood via the same initial
scale. These answers are all electronically sorted and recorded to built a data table that can
display the overall effectiveness of the application. Participants will use this application over a 6-
month period, in which data on move improvements will be recorded.
The first activity ReBoot offers is called “MoodScapes.” When selected, a photographic
of a calming scene is displayed (A beach, a forest, rolling hills, etc.) and nature sounds or white
noise may be selected by the user to play in the background.
The second activity is known as “Mind + Body.” When selected, the user will be
presented with a variety of fitness related activities that also aid in stress reduction. Breathing
exercises, yoga and tai chi instructions. The aim of this activity is to actively engage the user in a
physical healthy coping mechanism that will prove useful, even if they do not have access to
technology.
The third activity is “Stress Less Games.” When selected, the application offers you a
selection of games they can play that promote the “cognitive flow theory.” That is, to keep them
engaged and involved, causing instances of cognitive and abstract thinking. These games are
recommended to be non violent, and constructive in some form (building, shaping, operating).

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The fourth activity is called “Compliment Corner.” When selected, the user is presented
with a list of compliments (“You’re awesome”, “You’re fantastic”) and they may select a
compliment to be sent to another random user of the application. They will not know the persons
name, picture, nor will they be able to contact them in any way. All they will see is the kind
words a human being sent. It is through this activity the application seeks to promote user self-
confidence, self-image, as well as witnessing first hand, the kindness of others.
The fifth and final activity is known as “Counselor Connect.” When accessed, the user
may access a secure portion of the application where they may view topics they have been
discussing with their own personal counselors. Especially when clients have “homework” to
complete, this is a tool used for time management and reminders to work on activities they’ve
been given.
Participants
The target sample for this study will focus on individuals already seeking counseling for
problems related to stress and anxiety. Participants will complete the Depression Anxiety Stress
Scales (DASS) assessment, which is a set of three self-report scales designed to measure the
negative emotional states of depression, anxiety and stress (Lovibond, 1995). Those who
exhibited indicators of anxiety and stress will then be randomly selected until we have our
sample size of 100. This 100 is then randomly divided into two groups of 50. The experimental
group will use the application Reboot in conjunction with their regular counseling sessions. The
control group will receive only their regularly scheduled counseling sessions. After 6 months, the
DASS will be administered once again to both groups, and the changes in results will be
analyzed.

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Ethical Considerations
Given the sensitive nature of individual’s medical records, it is only natural to question
the security of participants whom are openly willing to engage in this experiment. To ensure the
safety of client’s data and confidentiality, the application will require users to enter a 4 digit
numeric password before they may access the applications features. For devices that incorporate
fingerprint scanners, users may choose to scan their fingerprint, as this “security code” is unique
to the individual. Participants should be informed however, that while these safe guards have
been put into place, they can never 100% guarantee confidentiality when the client has access to
this information. Once the trial has concluded, participants will be instructed on how to
permanently erase their data from the device. Upon removing the application from their mobile
device, the application will alert them that all data and progress will be permanently deleted, and
they will then be required to enter their security code to verify they understand this. Upon
deleting the application, all user data is removed from the device. All that remains is the
anonymous data recorded to assess the effectiveness of the application.
Measures
According to Peter Lovibond (1995) the scales of the DASS have been shown to have
high internal consistency and to be versatile in a variety of settings. The scales should meet the
needs of both researchers and clinicians who wish to measure current mental state and/or
changes in mental state over time. Participants will complete this assessment immediately
preceding their first time using the application, and again once the 6-month trial period has
passed. It is through this that we seek to analyze changes in the pre and posttest setting.
Assuming that the measure is reliable, individuals will exhibit differences in their pre and post
assessment results.

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Aside from the DASS assessment, participants are asked to rate their mood on a 1-10
scale. They are asked to do this when the app begins, and when they switch between activities.
This is how the application seeks to establish face validity. If the users themselves report
improvements in mood, this helps show that at least “on it’s face” it is effective. Though this is
generally not enough to measure validity.
The DASS assessment allows researchers to measure content-based validity. Individuals
using this application have already been assessed as having high levels of anxiety and stress.
Upon completion of the trial, the hypothesized decrease in levels of anxiety shows that the
content of the mobile application has a direct effect upon participant’s levels of anxiety and
stress.
Procedures
Participants using ReBoot will complete the DASS assessment before and after the
experiment. ReBoot will also record their mood responses during the use of the application. This
data is sorted electronically into categories of age, sex, activity and mood changes. The changes
in mood in correlation to activities used and the pre and post DASS scores are then analyzed to
determine the effectiveness of the application, as well as which activities showed more or less
beneficial than the others.
Threats to Validity
In a study such as this, one of the main threats to validity is software error and human
error. Assuming something happens to the application, users may have problems accessing it,
making their experiences less than positive. To combat this, it is important to remember the
importance of maintaining the software and electronic updates necessary to ensure the

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application works for every user every time, and if there are problems, they must be fixed
effectively and quickly.
In terms of human error, it is possible that a client may misread directions, or accidentally
submit their mood as a 4 when they really meant 7. When errors like these occur, it is important
that the user has an open form of communication with their counselor so that they may inform
them of this error so that it may be changed within the computer systems and noted. Finally,
there is also the notion that not every single person is receptive to the same form of therapy.
Certain participants may report not liking the idea of the application. This can skew results on
their mood as well as their post DASS assessment.
Anticipated Results
It is my hope that participants using the application ReBoot will exhibit reduced instances
of stress and anxiety by at least 25% greater than the reduction of those who participated in
counseling alone. With having at improvement of 1/4 of the test population, I feel exhibits a high
enough improvement to establish a need for technologies such as this, and for further research
and developments.
Anticipated Limits
One of the largest limitations to studies involving new technologies is an individual’s
access to the technology. While the smartphone market is increasing exponentially, users do only
account for around 45% of all cell phone users. This means that only 45% of all cell phone users
have the possibility to access an application like ReBoot. Furthermore, there are only a finite
number of ways this application can aid in the counseling process. While the possibilities may be
numerous, the application is not intended to replacing working with a professional counselor or
psychotherapist when it is necessary. ReBoot is designed as a tool to maintain general mental

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health. Much like your smartphone cannot cure cancer, it is not possible to accurately diagnose
and treat severe mental disorders using this method of treatment. There is always room for
technology in the field of counseling and psychotherapy, but at no point should the complete
focus turn away from the human experience.

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