Beyond the Bounds - June 1, 2019
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Helping Cancer Patients Reduce Psychological Distress with Metaphors in a Serious VR Game

By Matthew Lemmond

The Problem

The mind’s impact on cancer’s ability to grow is on the horizon—if not well beyond the bounds—of academic research.

38.4%of people in the U.S. will receive a cancer diagnosis in their lifetime (Cancer Statistics, 2018). Those facing a life-threatening illness are likely to experience what is known as psychological distress—negative emotions that impede everyday activities (Ridner, 2004). A warped sense of the self and one’s circumstances is common with psychological distress, and patients commonly experience depression and anxiety as a consequence of their illness (Gundelach & Henry, 2016). Cancer-related psychological distress distinguishes itself as a patient’s negative emotional response to a cancer diagnosis and includes four attributes—depression, anxiety, fear, and feeling discouraged. These people experience distress because of the unknowns of cancer and would identify with questions like the following: Why me? Will the treatment work? Will the cancer come back? Did I do something to deserve this? I’ve lived a simple life; why did I get cancer? When will the pain go away? Who will take care of my children? Will I live long enough to walk my daughter down the aisle?

This is a 3D recreation of a typical chemotherapy infusion facility.

This is a 3D recreation of a typical chemotherapy infusion facility.

Cancer-related psychological distress has serious consequences. According to Psychology Today, 45% of survivors experience anxiety and 25% experience depression (“Neglecting Mental Health in Cancer Treatment,” 2017). As Brower (2014) points out, depressed survivors are twice as likely to die prematurely. Abrams (2017) notes that many patients experience Post-Traumatic Stress Disorder (PTSD) and that suicide is twice as likely for cancer survivors as compared to the general population. Cancer patients with high levels of distress have a 32% greater chance of dying (Batty et al., 2017).

In contrast, according to the National Cancer Institute (NCI), “there is no evidence that successful management of psychological stress improves cancer survival;” however, NCI goes on to acknowledge that evidence from experimental research suggests a tumor’s ability to grow and spread can be encouraged by psychological stress (“Psychological Stress and Cancer,” 2012).

What the NCI calls “experimental research,” others call “strong evidence.” Mental activity affects behavior, and behavior can negatively influence physiological (bodily) and molecular processes like cellular apoptosis (cell’s self-destruction procedure), the rate of cellular mutation through the discharge of stress hormones, and immunity (the body’s defense system), and therefore the speed at which cancer grows (Cordella and Poiani, 2014).

The Intervention

The academic evaluation of metaphor in gaming is on the horizon of academic research, and the use of metaphor as a way of understanding cancer in VR is well beyond the bounds of academia.

Cancer is, at least in part, beyond the understanding of even our greatest minds and buried in the essential elements of our biology, and as a result, must be undertaken with a broad range of experts beyond traditional medicine. Consequently, it should not be surprising that patients struggle to understand their future with this disease. Cancer is an unknown entity. Fearing the unknown future is a source of distress for cancer patients.

As previously mentioned, cancer-related psychological distress can distort the image patients have of themselves, as well as their cancer, treatment, and circumstances. In collaboration with treatment, coping with stress can help, at least to a degree, in the prevention of some cancer types (Cordella and Poiani, 2014). The patients use of metaphor is one form of coping. Metaphors help patients make sense of their past, present, and future experiences with cancer.

In conceptual metaphor theory, a metaphor is pervasive and foundational in everyday language and thought (Lakoff & Johnson, 2003). Conceptual metaphor theory posits that our brain maps the source and target domains of an entity or action to understand the world better. For example, cancer (target), is a fight (source). This investigation and supporting research posits that to the cancer patient, a metaphor is shielding, playful, communal, a bodily experience, educational, allows for control, and provides perspective.

Additionally, this investigation asserts that serious games in VR can improve cancer patients embodied conceptual metaphors. Embodiment refers to the idea that cognition and communication form by physical experience and bodily interaction with a tangible world, as well as giving shape to thoughts and feelings (Davis, 2012). A serious game is any game designed for something other than pure entertainment.

According to Fahlenbrach (2016), “In the most general sense, video games—and also other forms of play, for that matter—can be regarded as metaphoric in that they involve a mode of ‘playing as’” (p. 252). The user is ‘playing as’ a character within the game and gains said character’s abilities. In VR, the embodied conceptual metaphor ‘playing as’ is strengthened by what Jason Jerald, Ph.D. (2016), author of The VR Book, calls “self-embodiment,” which is “the perception that the user has a body within the virtual space” (p. 47). However as previously stated, cancer is an unknown. What should happen when the experience is unknown?

VR is a medium that can visualize metaphors or provide alternative ones that help distance patients from cancer and regaining control over it. The design of a VR space can visualize abstract ideas. Our imagination is as a stage where we can visualize and rehearse for alternative roles and scenarios. According to Sadoski & Paivio (2013), “a key feature of human imagination is the ability to rearrange our world or to create new worlds (p. 65).” However, our imagination is limited to our past experiences.

For a cancer patient, their unknown future with cancer is a source of anxiety. Additionally, cancer can be mysterious, unpredictable, and unfamiliar to the patient. What if a VR experience helped cancer patients see themselves in alternative roles and scenarios? This investigation will explore such questions.

VR as a distress intervention is within the bounds of academic research. In addition to the metaphorical benefits of VR, the medium also helps with psychological distress. A mini-review by Chirico et al. (2016) used VR with 839 patients and concluded that “VR improved patients’ emotional well-being, and diminished cancer-related psychological symptoms” (p. 1). Fourteen of the nineteen articles in this mini-review studied VR and anxiety, and four studied VR and depression. According to Dr. Susan Schneider, an associate professor at Duke University School of Nursing and an oncology nurse with 30 years of experience, “by decreasing chemotherapy-related symptoms [like anxiety], virtual reality has the potential to increase compliance with treatments, affect survival, and enhance the quality of life” (Schneider et al., 2004, p. 1). Quality of Life (QoL) is an individual’s assessment of physical, mental, emotional, and spiritual well-being. Additionally, Dr. Schneider describes VR headsets as “horse blinders” because they block out all the visual stressors.

Interestingly, Chirico et al.’s (2016) mini-review makes no mention of what the viewer sees in the VR experiences. It is not until reading the individual articles that one gets anything about the multimodal content of the VR experience. The mini-review examined nineteen articles, but few of them thoughtfully examined what the user sees in VR.

Missing from this research is a critical evaluation of the patient’s source of distress as well as patient’s source of comfort and the metaphors they use to describe their experience with cancer as well as how that can inform the plot and entities of a serious VR game.

This Investigation

How can a patient’s source of distress, source of comfort, and the metaphors they use to describe their experience with cancer inform the design of a serious VR game aimed at reducing cancer-related psychological distress?


Figure 1. Map of cancer patients’ distress, comfort, and metaphors, connected to VR game concepts and interactions.

Figure 1. Map of cancer patients’ distress, comfort, and metaphors, connected to VR game concepts and interactions.

“Cancer in other words? The Role of Metaphor in Emotion Disclosure in Cancer Patients” is an article by Lanceley and Clark (2013) that analyses the metaphorical concepts patient’s use for cancer-related psychological distress. Based on the work of Lanceley and Clark, this investigation mapped cancer patients distress, comfort, and metaphors, and connected it with VR game concepts and interactions (Figure 1).

In VR, immersion is where the user psychologically feels as though they are somewhere else (Jerald, 2016). He defines immersion as comprised of six parts: extensiveness, matching, surroundness, vividness, interactability, and plot (p. 45).

Extensiveness refers to “the range of sensory modalities presented to the user (e.g., visuals, audio, and physical force)” (Jerald, 2016, p. 45). Matching is the congruency between the users real body and their virtual body. Surroundness “is the extent to which cues are panoramic” (Jerald, 2016, p. 45). Vividness refers to the quality of resolution. Interactability refers to the user’s ability to alter and influence their virtual world and other entities within it. And finally, plot refers to the story or narrative. While all the parts of immersion provide opportunities for metaphor, plot is especially ripe for metaphorical expression.

Concept One: Breaking Out of the Hospital and Into Nature

Figure 2. This is a video of the themes discussed in concept 1.

Helen expressed psychological distress when contemplating further treatment and hospitalization (Lanceley & Clark, 2013). She seems to connect the fear of being continually confined to the hospital with her “worst destiny,” of being disabled and confined to her apartment. In contrast to this theme of continued confinement, she finds comfort in the idea of controlling her destiny. The metaphor, treatment is jail, seems to fit well with her distress.

Helen’s distress and comfort call for a game plot in which she leaves a confined place that resembles the treatment facilities and enters an open-world of endless possibilities. This concept is reinforced by Forceville and Paling (2018) when they say “depression is a dark confining space” (p. 1) which the patient is leaving.

This gaming experience becomes immersive when the user’s body movements match their virtual movements naturally in space and the extensiveness of sensory modalities.

Concept One: Conclusion

In concept one, the patient is in a familiar hospital setting that is dark and depressing (Forceville and Paling, 2018). This idea of darkness is echoed by metaphors in Tanner’s (2017) Cancer Metaphor Test (CMT) like: cancer is a river of darkness, a haunting shadow, free fall through the black chasm, the dark secret, and thick black tar (Tanner, 1997). Additionally, Domino and Pathanapong (1992) confirm this idea of darkness in the Cancer Metaphor Test (CMT) with the metaphor: cancer is a dark cloud. Using physical force, the patient can break through the wall, thus embodying the experience of being a powerful entity that can move freely.

Concept Two and Three: Cancer as an Obstacle that the Patient Can Control, and Patient as Caregiver

Figure 3. This is a video of the themes discussed in concepts 2 and 3.

Concept Two: Cancer as an Obstacle the Patient Can Control

Mary, Helen, and Doris all expressed distress over their loss of control and found comfort in controlling their destiny. The distress and comfort surround the loss of control had multifaceted expressions.

Helen communicated her loss of control through her distress with waiting on test results. She metaphorically compared waiting for results to the suspenseful build-up rugby players feel before an important match. Helen becomes more immersed in this metaphor by describing the medical staff treating her as a strong rugby team. She finds comfort in thinking about the medical staff being tough, strong, and aggressive. Unfortunately, she does not see herself as a member of the team. Instead, she is powerless and can only watch from the sidelines.

Doris communicated her loss of control with her distress with playing “sick role.” She is struggling with the incongruence between her current illness and a lifetime of good health. Doris finds comfort in her toughness. She metaphorically describes herself as being “tough as old boots” and is troubled by being in the hospital, which is only for weak people.

Mary communicated her loss of control with her distress over not being able to get straight. She metaphorically connects her physiological problem of not being able to straighten her shoulders with her psychological problem, not being able to straighten out or make sense of her situation with cancer. The metaphor, cancer is crooked, seems to fit well with her distress. Doris also struggled to make sense of her situation with cancer. For her, telling a chronological story may indicate an attempt to bring some semblance of order and rationality to her illness. Metaphorically speaking, cancer is messy. Mary also struggles with the incongruence between the simple life she has led and the complexities of cancer.

These sources of distress and comfort call for a game plot in which the patient is powerful, in control of cancer, and bringing order to their world. This concept becomes VR specific through interactability by manipulating cancer with physical force.

Concept Three: Patient as Caregiver

While Helen was the only patient to express fear about being alone explicitly, both she and Mary expressed comfort with the idea of caring for others entities, like humans and animals (Lanceley & Clark, 2013). This CMT metaphor supports the concept of tending: “cancer is being alone in the forest” (Domino and Pathanapong, 1993).

This distress and comfort call for a game plot in which the patients takes on the role of a caregiver and has social opportunities. This concept becomes VR specific through proximity and interactability with other game entities. Interactability is another core element of immersion (Jerald, 2016).

Concept Two and Three: Conclusion

Together, concepts two and three explore the metaphor that cancer is an obstacle on life’s journey (Gibbs & Franks, 2002; Harrington, 2012). Here, the user finds a cancer-like obstacle blocking the flow of water, consequently making the river stagnant—stagnant water being another metaphor used to describe cancer (Tanner, 1997). The user can remove the obstacle, thus restoring order to their virtual world.


Laurence Kirmayer (1993) proposes that if every interpretation of distress is, at root, the invention of metaphors for experience, healing may occur not because a conflict is accurately represented, or even symbolically resolved, but because the metaphorization of distress gives the person room to maneuver, imaginative possibilities, behavioral options, and rhetorical supplies. (p. 165).

This investigation proposes concepts for metaphorically representing a cancer patient’s psychological distress and the VR elements that give them room to maneuver around said distress. These concepts, in part, present how the design of a serious VR game can transform a patient’s embodied metaphorical conceptualization of their cancer from a negative source of anxiety and depression to a positive opportunity for personal growth.

Matthew Lemmond (MGD ‘19) is a recent graduate of North Carolina State University’s Master of Graphic Design program. He’s interested in reducing the psychological burden of cancer in patients using embodied metaphors in VR.


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