Introduction

Psychosocial professionals treating children with cancer benefit from an array of tools that allow the expression of feelings, concerns, hopes, and fears. There has been growing awareness of the usefulness of therapeutic board games when counseling children [1, 2]. A board game provides structure, familiar format, a start/end position, turn-taking, and rules and boundaries, all of which provide a sense of safety [3]. Therapeutic board games provide children opportunities to address feelings they may find difficult to express through traditional talk therapy. Therapists use board games to develop therapeutic relationships, provoke conversation about stressful topics, assess for emotional distress and family conflict, and to elicit specific concerns and anxieties [2, 4]. While playing board games, children are often more open to trying new behaviors, addressing problem solving, and gaining insight into their difficulties than when receiving direct suggestions from an adult [2, 5].

There has been an increase in the number of therapeutic board games in recent years for use with both general feelings [6, 7] and for specific issues such as anger management [8], impulse control [9], sexual abuse [10], grief [11], and bullying [12]. Medically ill children often have little control over events in their lives. Through medical play, hospital-based child-life programs help prepare children for surgery, diagnostic testing, and painful medical procedures. Few tools are available, however, to help medically ill children and adolescents relax defenses and encourage self-expression. This paper describes the development of ShopTalk, a therapeutic game created for pediatric oncology patients and the findings from a survey designed to assess utilization of the game in clinical settings. At the time ShopTalk was developed, only one game, Adventure Park [13], was available for youth with cancer. This game is no longer produced.

Game development

ShopTalk is a therapeutic board game developed to help children ages 7–16 years living with cancer talk about their illness in a non-threatening, fun, and creative way. In 1998, the author (LW) created a therapeutic workbook titled, This is My World for children with serious medical illnesses [14]. Throughout the pages of the workbook, children have the opportunity to share their thoughts, concerns, and wishes about how they see themselves and understand their illness and prognosis. As children often asked to work on their workbook, it became clear that asking children questions in a “fun” and non-threatening format could be emotionally fulfilling for the child. In order to expand on the opportunity to increase communication with seriously ill children, the author (LW) decided to create a game using the questions in the workbook. The concept for ShopTalk was developed by the authors (LW, CM), the artwork designed (CM), with additional questions based both on clinical experience and the literature (LW). Over several years, as the game prototype was used during therapeutic sessions with children living with cancer and HIV infection, players were encouraged to create new questions. These questions were informally “tested” over time, and many became part of the game. ShopTalk was piloted for use within inpatient and outpatient settings and in one-on-one and group therapeutic sessions with up to six players.

Game content

ShopTalk consists of a colorful board with ten stores, each with a set of 15 question cards related to the theme of the individual store (150 questions total). Questions are written in English and Spanish. The stores' names reflect the concerns of youth living with serious illness. The questions in each store are primarily open-ended questions, leaving room for creative responses. For example, the “Unconditional Love” pet store provides questions that specifically explore the people and parts of the child's life that are most accepting, supportive, and helpful as well as the child's fears of rejection and/or abandonment. The “Balls in Your Court” sports store presents different social scenarios that often occur during treatment and ways the child could, did, or would like to handle these situations. The questions for all the stores may be quite simple and innocuous (e.g., “What is your favorite movie?”; “If you could spend one day doing anything and everything you wanted, tell us what that day would be like.”; “Tell us about a time when you felt proud of something you did.”; “Tell us about the greatest day of your life.”). Other questions are more thought-provoking, with some specific to cancer and others more general. Examples of questions in the store named “Imagination”, include “Imagine that there is an x-ray machine for feelings. What would the x-ray show as the feelings inside of you?” and “Imagine that you were never diagnosed with cancer. How would your life be different right now?”. Certain cards were created for deeper exploration (“If you could go back and change something that you said or did in your life, what would that be?”; “Who in your family is having the most difficult time?”; “If you could change anything about your personality, what would you change?”; “Do you ever have thoughts that race through your head at night when you are trying to fall asleep? If so, tell us about some of those thoughts”; “Describe a time when you felt like no one could really understand what you were going through”; “Do you think that if a child's disease cannot be cured that the child should be told? If so, who do you think should tell the child—the doctor or the parent or someone else?”) (Table 1).

Table 1 ShopTalk store names, sample questions, and gift items
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Game rules

Players roll the dice to move their “shopping bag” piece around the board attempting to enter each store, at which point they become a “customer” and are asked a question by another player. The customer has two options—“buy” the store's product by answering the question or say, “I'm just looking” and choose not to answer the question. The option to “just look” allows a player to gracefully decline answering a potentially threatening question. If the player decides to answer the question (“buy”), he/she receives a token from the store. The first person to fill their shopping bag with a token from each of the ten stores wins.

Questions elicit information on coping, peer relationships, body image, family dynamics, and adherence, while also screening for symptoms of anxiety, depression, and expectations about disease outcome. The therapist's primary role is to facilitate the game by providing a safe space for the player to share and express his/her thoughts and feelings. Therapists can choose in advance, which questions to include based on the individual player(s) needs. Following a player's response, the therapist can simply acknowledge the answer or choose to ask supplementary questions, enabling continued discussion. The therapist may join the game as a co-player, but always takes the role of a facilitator. As co-player, the therapist can model behavior and share an appropriate amount of personal information to reduce the players' discomfort with being the only discloser. Careful judgment is always needed.

Study purpose

ShopTalk has been available to professionals since mid-2009. The purpose of the present pilot study was twofold: (1) To gather qualitative information regarding the usefulness of ShopTalk in building a therapeutic relationship and assessing psychosocial concerns, and (2) to assess practitioner feasibility of using the game. The researchers (LW, HB) created an online survey to assess the clinical and practical experiences of professionals who received ShopTalk, as well as to identify barriers to its use. Both those who had used the game in their practice and those who had received it, but not used it, were asked to complete the survey.

Study design

A letter was sent to major pediatric cancer centers informing them of the game's availability; 70 games were requested and distributed. In addition, 160 games were distributed to attendees of the 2009 American Pediatric Oncology Social Work (APOSW) annual meeting. The National Cancer Institute covered the costs associated with manufacturing and shipping the game. Four months following distribution, direct requestors of the game and attendees of the APOSW meeting were contacted by e-mail and informed about this study. Unfortunately, the researchers did not have the e-mail addresses of the specific conference participants who received the game and were therefore unable to calculate an exact response rate. Those contacted were informed that the goal of the survey was to obtain information about their clinical experience using ShopTalk. Each group was sent two reminder e-mails, approximately 3 weeks apart. One hundred and ten practitioners completed the survey.

Descriptive statistics were used to summarize the data. To further elucidate the experience of using ShopTalk in clinical practice, the survey included several open-ended questions. Participants were asked to address what they found most and least helpful, difficulties encountered, and recommendations for future versions. Two independent researchers utilized an open coding procedure to identify themes of the responses. Responses could be coded into as many categories as were applicable. When themes differed between researchers, they met with each other and the principal investigator (LW) for discussion in order to reach consensus.

Results

Of the 110 respondents, 62 (56%) had used ShopTalk in their clinical practice and 48 had not. Only 7% of those who had not used the game felt it was inappropriate for their patients; the rest indicated plans to use ShopTalk in the near future. The current analyses are focused on the 62 respondents who reported using the game. The majority of respondents had masters (44%) or doctoral (35%) degree.

Practice setting

Seventy-nine percent of respondents used ShopTalk in individual therapy sessions, 26% in groups and 28% in family sessions (responses not mutually exclusive). ShopTalk was used with oncology patients (74%) and with patients with other medical illnesses (30%). Practitioners used ShopTalk with children ages 9–12 (74%), adolescents (42%), and children under 9 (42%).

Clinical use

General feedback from clinicians using ShopTalk has been overwhelmingly positive, with 96% planning to continue usage. Ninety-two percent of participants used the game for rapport building, indicating that ShopTalk was “pretty useful” or “very useful” in assessing and facilitating communication about coping skills, family relationships, identification of stressful issues, adjustment/adaptation, self-esteem, peer relationships, depression/sadness, and a patient's view of prognosis (Fig. 1). ShopTalk was reported valuable during the entire cancer trajectory and particularly helpful during and post-treatment (Fig. 2). Respondents commented on the flexibility of using the game in both inpatient and outpatient settings.

Fig. 1
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Utility of ShopTalk for different therapeutic goals

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Fig. 2
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Appropriateness of playing ShopTalk during the cancer trajectory

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Qualitative responses were coded into the following domains: ShopTalk is useful as an introduction to, and for engagement in therapy; helps patients express feelings; helps reveal patients' understanding and concerns; provides a safe environment; covers a wide variety of topics that may not usually arise; and useful in informing case conceptualization and treatment intervention selection, developing coping skills, fostering awareness of patient/family strengths, validation of feelings and reduction of isolation (Table 2).

Table 2 Quotes from respondents about ShopTalk
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Challenges using ShopTalk

Although professional response to ShopTalk was overwhelmingly positive, limitations were noted including: cards specific to cancer not being useful for children with other diagnoses (11%), the board can be confusing for children with neurocognitive and/or visual processing deficits (8%), the set up is time consuming (6%), and not knowing how much information to share when the clinician is a co-player (4%). In response to the survey results, the researchers developed an online training video that addressed these issues [15]. This video, along with a written description addressing frequently asked questions, was emailed to game recipients as supplementary directions on how to best use ShopTalk in a clinical setting.

Respondents were forthcoming with suggested improvements. While the game was created for children living with cancer, 30% reported successfully using the game with children with other medical illnesses. These respondents suggested having more general cards or more illness-specific cards (for illnesses other than cancer). In the training video, clinicians are encouraged to create cards that can be tailored to their individual patients. Therapeutic value has been found in asking the children to come up with their own “good” questions.

Clinical implications

ShopTalk is a new therapeutic tool designed to help children and adolescents living with cancer address their feelings about how their illness affects their life. The survey results suggest that ShopTalk is a beneficial therapeutic tool for building rapport; identifying and discussing difficult issues; gathering information pertaining to coping skills, family, and peer relationships; and understanding adjustment and adaptation to illness.

Whereas some games are designed for use by a clinician who already has a trusting therapeutic relationship with the child, ShopTalk is successful in helping develop such a relationship. It is important to note that ShopTalk was specifically designed for use by professionals with clinical training. A therapeutic response within a child's play language requires that the therapist first understand what the child is communicating and how this communication reflects interactions and/or feelings from the child's life. Unless the clinician responds consistently to the child during the play, the playing of a game may not be therapeutic (apart from the opportunity it provides to build a relationship with the child) [4].

Features needed to make a therapeutic game attractive to school-age children are the possibility of winning and the opportunity for a therapist to model “feeling” responses that the child may initially consider inappropriate [4]. ShopTalk meets both of these criteria. For example, when a therapist co-player is asked, “What is the worst thing that someone can say to you?” and the therapist responds with “I might look ugly with no hair”, the child learns that talking about embarrassing issues is acceptable. Moreover, “Do you think that you will survive your illness?” allows the child to speak thoughts they might have been harboring about their prognosis. Being able to choose whether or not to answer specific questions allows the child to feel a sense of control—an issue with which medically ill youth struggle with. Being rewarded with a token for each response further motivates some children to answer each question.

Study limitations include the small sample size and self-selected participants. The survey examined the feasibility and utility of ShopTalk from the clinicians' perspective within the first year of its availability. Although clinicians reported the game to be useful in areas such as identifying coping skills and adaptation, the field of psychooncology would benefit from empirical research that determines therapeutic efficacy with game play. A randomized controlled trial using different therapeutic interventions, including ShopTalk, would help answer questions pertaining to efficacy.

Conclusion

ShopTalk is currently the only known therapeutic game available for children and adolescents living with cancer. The results suggest that ShopTalk is a fun, interactive, and effective tool to explore several psychosocial domains throughout the course of illness, encourage rapport-building between the patient and clinician, and assist with directing communication in family and group settings. Although ShopTalk was initially designed for use with pediatric oncology patients, the findings suggest that ShopTalk can be an effective tool with patients of various ages and medical conditions. Respondents also expressed interest in a version of ShopTalk for children who have a parent with cancer and as a bereavement tool. ShopTalk has now been requested in most major cancer centers in the USA and in 14 countries. Programs and clinicians interested in learning more about ShopTalk or wishing to obtain a copy of the game can do so by contacting the author (LW) or online at: http://pediatrics.cancer.gov/scientific_programs/psychosocial/educational.asp.