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Breathing out: a therapeutic virtual reality experience

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Breathing out: a therapeutic virtual reality experience

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Content Copyright 2024 Tianxi Ren
BREATHING OUT:
A THERAPEUTIC VIRTUAL REALITY EXPERIENCE
by
Tianxi Ren
A Thesis Presented to the
FACULTY OF THE USC ROSKI SCHOOL OF ART AND DESIGN
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF FINE ARTS
(DESIGN)
May 2024

ii Copyright 2024 Tianxi Ren
Acknowledgments
I would like to express my deepest gratitude to Laurie Burruss, Marientina Gotsis, April
Greiman, and Bruno Lemgruber, my thesis committee members, and Jeffery Newell, my external
advisor, for their invaluable guidance, unwavering support, and insightful feedback throughout
the entire research process. Their expertise and encouragement significantly contributed to the
completion of this thesis.
My appreciation goes to the Roski School of Art and Design at the University of
Southern California for providing the necessary resources and a conducive academic
environment.
I am indebted to my colleagues and advisors for engaging in discussions, constructive
criticism, and thoughtful suggestions. Special thanks to Yifan Pu, Yicong Wu, and Feiyang
Zhang for their collaboration and assistance with the development of the VR experience.
My sincere gratitude is extended to my friends and family for their encouragement,
understanding, and patience during this challenging academic endeavor. Their emotional support
provided the foundation for my perseverance.
Lastly, I want to thank all the participants who generously contributed their time and
insights to this thesis project.

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TABLE OF CONTENTS
Acknowledgments........................................................................................................................... ii
List of Figures................................................................................................................................ iv
Abstract........................................................................................................................................... v
Preface............................................................................................................................................ vi
Chapter 1: Exploring Stress and Anxiety Among Young Adults................................................... 1
1.1 Prevalence of Mental Health Issues in Young Adults............................................. 1
1.2 The Role of Traditional Therapy and Its Barriers................................................... 3
1.3 Game and Its Potential in Mental Health Prevention .............................................. 5
Chapter 2: Therapeutic Principles and Practices Incorporated into Game Design......................... 7
2.1 Positive Imagery in Cognitive Behavioral Therapy ................................................ 8
2.2 Self-counseling through Virtual Body Ownership................................................ 10
2.3 Meditation and Mindfulness-Based Cognitive Therapy ....................................... 12
2.4 Art and Music Therapy.......................................................................................... 14
2.5 Ecopsychology and Eastern Beliefs in Yin-Yang and Five Elements .................. 16
Chapter 3: Case Studies of Existing Products............................................................................... 19
3.1 Nevermind............................................................................................................. 19
3.2 TRIPP .................................................................................................................... 21
3.3 Blowing Blues....................................................................................................... 22
Chapter 4: Developing Breathing Out – A Therapeutic VR Experience...................................... 24
4.1 Level Design.......................................................................................................... 24
4.2 Visual and Audio Design ...................................................................................... 33
4.3 Storytelling ............................................................................................................ 35
4.4 Interactive Experience Design............................................................................... 35
Chapter 5: Conclusion................................................................................................................... 37
5.1 Conclusion............................................................................................................. 37
5.2 Suggested Future Research ................................................................................... 37
Bibliography ................................................................................................................................. 39

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List of Figures
Figure 1: Image showing “Share of Adults Reporting Symptoms of Anxiety and/or Depressive
Disorder, February 2023”. .............................................................................................................. 2
Figure 2: Screenshot of SPARX 2 gameplay................................................................................... 9
Figure 3: The Counseling Scenario............................................................................................... 11
Figure 4: Screenshot of TRIPP gameplay..................................................................................... 13
Figure 5: Setup for Creative Expression in Virtual Reality.......................................................... 15
Figure 6: Screenshot of Nevermind gameplay showing biofeedback in action............................ 20
Figure 7: Screenshot of Blowing Blues Gameplay. ...................................................................... 22
Figure 8: Illustrated prototype for Breathing Out Phase I: Connection........................................ 25
Figure 9: Illustrated prototype for Breathing Out Phase II: Stimulation...................................... 26
Figure 10: Illustrated prototype for Breathing Out Phase III: Labeling ....................................... 28
Figure 11: Illustrated prototype for Breathing Out Phase IV: Regulation.................................... 29
Figure 12: Illustrated prototype for Breathing Out Phase V: Defusion........................................ 31
Figure 13: Illustrated prototype for Breathing Out Phase VI: Return .......................................... 32
Figure 14: Wallpaper for Monument Valley ................................................................................. 33

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Abstract
Breathing Out
Tianxi Ren
Stress and anxiety are becoming more prevalent among young adults worldwide as
technology ushers people into an era of information explosion. These negative feelings, if left
unresolved, can lead to more severe mental illness. However, traditional in-person therapy may
face barriers, such as stigma and dropout. To address this, games have emerged as a promising
approach to relieving mental illness. Among the various forms of games, virtual and augmented
reality games have been identified as particularly effective due to their immersive and interactive
nature.
This thesis explores the potential of using therapeutic and reflective virtual reality (VR)
experiences to assist young adults in dealing with stress and anxiety. By incorporating innovative
problem-solving, positive imagery that aligns with the principles of Cognitive Behavioral
Therapy, and assisted meditation, Breathing Out, a VR experience, aims to educate and train
young adults in practical coping skills to combat stress and anxiety effectively.
The comprehensive research and existing literature on games indicate their potential as
effective solutions in preventing mental health issues. Interviews with professional psychologists
and therapists serve as the primary source of inspiration for narrative and gameplay design.
Additionally, studies of existing products in the field provide insights into successful approaches
that can be incorporated into Breathing Out.
Keywords: stress, anxiety, mental health, game, virtual reality, interaction design, meditation,
therapeutic experiences

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Preface
Welcome to the MFA Design thesis "Breathing Out: A Therapeutic Virtual Reality
Experience." This work encapsulates two years of rigorous research and personal exploration
within the realm of interdisciplinary game design and mental health education. My focus
throughout this academic endeavor has been to understand how immersive technology can be
harnessed to assist young adults in coping with mental health challenges.
In the opening chapter, you'll encounter an exploration of mental health issues prevalent
among young adults, an introduction to conventional therapeutic practices, and a critical analysis
of existing products in this domain. Subsequent chapters detail the development process of the
VR experience Breathing Out, encompassing aspects such as level design, visual and audio
aesthetics, narrative intricacies, and interaction dynamics.
As you embark on this intellectual journey within the pages of this thesis, I encourage
you to critically engage with the content, delving into the nuanced dimensions of Breathing Out.
May this work make a substantive contribution to academia and serve as a wellspring of
inspiration for those venturing into the intersection of interactive media and psychology.

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Chapter 1: Exploring Stress and Anxiety Among Young Adults
In the contemporary digital landscape, mental health concerns among young adults are
increasingly prevalent, with conditions like anxiety, depression, and stress affecting this
demographic significantly. This chapter analyzes the gravity of this issue, influenced by factors
such as the pervasive impact of social media and financial pressures during the transition to
adulthood. These external stressors compound young adults' vulnerability to mental health
problems, impacting their lives. Adding to this challenge are the barriers associated with
traditional therapy, including the stigma surrounding mental health issues, financial constraints,
geographical limitations, and lengthy waiting periods. Consequently, many young adults do not
seek timely support, leaving their mental health concerns unaddressed. In response to these
complexities, researchers are actively exploring innovative mental health support systems,
including games, a novel approach that has gained prominence. This chapter sets the stage for a
comprehensive examination of these pressing issues and innovative solutions, focusing on
enhancing mental health support for young adults in the digital age.
1.1 Prevalence of Mental Health Issues in Young Adults
Mental health issues encompass a spectrum of conditions, including anxiety, depression,
and stress. In today's modern digital environment, mental health issues among young adults have
become a topic of increasing concern. Studies consistently underscore the gravity of this
challenge. As Figure 1 shows, a substantial proportion of young adults (aged 18-24) in the US
are experiencing symptoms of anxiety and/or depressive disorder more than other age groups as

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of the year 20231. Several factors may contribute to the prevalence of mental health issues in this
demographic. For example, the pervasive influence of social media2 and the financial pressures
associated with transitioning to adulthood3 play pivotal roles. These external stressors can
increase young adults’ vulnerability to mental health issues.
Figure 1: Image showing “Share of Adults Reporting Symptoms of Anxiety and/or
Depressive Disorder, February 2023”. KFF, March 20, 2023. Original image available at
https://www.kff.org/mental-health/press-release/latest-federal-data-show-that-young-peopleare-more-likely-than-older-adults-to-be-experiencing-symptoms-of-anxiety-or-depression/.
The consequences of untreated mental health issues among young adults are profound.
Academic performance is adversely affected, decreasing productivity and impairing educational
1 “Latest Federal Data Show That Young People Are More Likely Than Older Adults to Be Experiencing Symptoms
of Anxiety or Depression,” KFF (blog), March 20, 2023, https://www.kff.org/mental-health/press-release/latestfederal-data-show-that-young-people-are-more-likely-than-older-adults-to-be-experiencing-symptoms-of-anxietyor-depression/.
2 John A. Naslund et al., “Social Media and Mental Health: Benefits, Risks, and Opportunities for Research and
Practice,” Journal of Technology in Behavioral Science 5, no. 3 (September 2020): 245–57,
https://doi.org/10.1007/s41347-020-00134-x.
3Alisia G. T. T. Tran, Christina K. Lam, and Eric Legg, “Financial Stress, Social Supports, Gender, and Anxiety
During College: A Stress-Buffering Perspective,” The Counseling Psychologist 46, no. 7 (October 2018): 846–69,
https://doi.org/10.1177/0011000018806687.

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attainment4. Socially, individuals may experience strained relationships and social withdrawal,
further exacerbating their condition. On an individual level, untreated chronic mental health
issues can potentially progress into more severe conditions, such as suicidal ideation and
behavior. Research shows that the presence of an anxiety disorder, especially panic disorder and
PTSD, is significantly linked to suicidal behavior5.
1.2 The Role of Traditional Therapy and Its Barriers
Mental health issues in young adults present a significant societal challenge. Traditional
therapy, encompassing a range of therapeutic methods, has conventionally been regarded as a
viable solution to address these concerns. It offers a structured, supervised environment where
individuals can explore their thoughts and emotions. However, as valuable as traditional therapy
is, many barriers prevent young adults from fully benefiting from its services.
One of the prominent barriers is the pervasive public stigma or personal stigma
surrounding mental health6
. Stigma has deep-seated roots in society, and young adults are not
immune to its effects. Fear of judgment and social repercussions often dissuades them from
seeking help, leaving their mental health struggles unaddressed. Addressing stigma is essential in
making traditional therapy more accessible and acceptable to this demographic.
Accessibility challenges further compound the issue. Traditional therapy often comes
with financial costs that are challenging for young adults, many of whom are students or early in
4 F Wagner et al., “The Relationship between Depression Symptoms and Academic Performance among First-Year
Undergraduate Students at a South African University: A Cross-Sectional Study,” BMC Public Health 22, no. 1
(November 11, 2022): 2067, https://doi.org/10.1186/s12889-022-14517-7.
5 Josh Nepon et al., “The Relationship between Anxiety Disorders and Suicide Attempts: Findings from the National
Epidemiologic Survey on Alcohol and Related Conditions,” Depression and Anxiety 27, no. 9 (September 2010):
791–98, https://doi.org/10.1002/da.20674.
6 Daniel Eisenberg et al., “Stigma and Help Seeking for Mental Health Among College Students,” Medical Care
Research and Review 66, no. 5 (October 2009): 522–41, https://doi.org/10.1177/1077558709335173.

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their careers; Moreover, geographical limitations can hinder their ability to access therapy
services, especially in rural areas; The limited choices and long waiting can also discourage them
from seeking timely support, considering their busy academic schedules7
.
While traditional therapy remains a valuable resource, it is essential to recognize that
young adults' mental health needs are evolving. Alternative approaches, such as online therapy
and digital mental health apps, have gained popularity among this demographic8
. These
alternatives offer flexibility, accessibility, and anonymity, which is particularly appealing to
young adults facing traditional therapy barriers. Another notable trend among young adults in
recent years is their increasing preference for non-traditional methods, especially self-care, to
manage their mental health9
. This trend signifies a shift towards greater autonomy and a
proactive approach to well-being. Self-care practices such as listening to music, mindfulness
meditation, and exercise empower them to take charge of their mental health and well-being,
offering a sense of control in a fast-paced and demanding world10. The trend underscores the
importance of holistic self-care routines tailored to individual needs, complementing traditional
therapy and professional support.
7 Sophie Leijdesdorff et al., “Barriers and Facilitators on the Pathway to Mental Health Care among 12-25 Year
Olds,” International Journal of Qualitative Studies on Health and Well-Being 16, no. 1 (January 1, 2021): 1963110,
https://doi.org/10.1080/17482631.2021.1963110.
8 John A. Naslund and Kelly A. Aschbrenner, “Technology Use and Interest in Digital Apps for Mental Health
Promotion and Lifestyle Intervention among Young Adults with Serious Mental Illness,” Journal of Affective
Disorders Reports 6 (December 2021): 100227, https://doi.org/10.1016/j.jadr.2021.100227. 9 Katherine A. Cohen et al., “Traditional and Nontraditional Mental Healthcare Services: Usage and Preferences
Among Adolescents and Younger Adults,” The Journal of Behavioral Health Services & Research 48, no. 4
(October 2021): 537–53, https://doi.org/10.1007/s11414-020-09746-w.
10 Maria-Antonia Martorell-Poveda et al., “Self-Care Strategies for Emotional Distress among Young Adults in
Catalonia: A Qualitative Study,” International Journal of Mental Health Systems 9, no. 1 (December 2015): 9,
https://doi.org/10.1186/s13033-015-0001-2.

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1.3 Game and Its Potential in Mental Health Prevention
Acknowledging these limitations within traditional mental therapy and the desire for selfsufficiency, researchers are actively exploring and formulating more comprehensive and
effective mental health support systems for young adults. Recently, a novel approach involving
the application of games to address mental illness has garnered increasing attention. Games
employed in mental health interventions are commonly referred to as “serious games.” Unlike
most commercial games created primarily for entertainment, serious games are intentionally
designed for therapeutic purposes, utilizing gamification to address mental health issues11. At its
core, gamification infuses game elements and principles into non-game contexts, offering a fresh
and engaging perspective on services such as mental health support. What makes games
particularly appealing to young adults is their inherent capacity to capture their attention and
motivation. The use of game mechanics, such as storytelling, rewards, and progression systems,
harnesses their intrinsic desire for achievement, making the therapeutic process enjoyable.
Studies have consistently shown promising outcomes, including reduced stress levels,
improved mood, and enhanced engagement in mental health interventions that use serious games
or incorporate gamification elements12. These positive results underline the potential of games as
a valuable tool in the mental health prevention toolkit. Among the various forms of games,
virtual and augmented reality (VR/AR) games have been identified as particularly effective due
to their controllable, immersive, and interactive nature13. VR/AR games provide a unique
11 Theresa M. Fleming et al., “Serious Games and Gamification for Mental Health: Current Status and Promising
Directions,” Frontiers in Psychiatry 7 (January 10, 2017), https://doi.org/10.3389/fpsyt.2016.00215.
12 Cecilia Cheng and Omid V. Ebrahimi, “A Meta-Analytic Review of Gamified Interventions in Mental Health
Enhancement,” Computers in Human Behavior 141 (April 2023): 107621,
https://doi.org/10.1016/j.chb.2022.107621.
13 Lichen Ma et al., “Integrating Virtual Realities and Psychotherapy: SWOT Analysis on VR and MR Based
Treatments of Anxiety and Stress-Related Disorders,” Cognitive Behaviour Therapy 50, no. 6 (November 2, 2021):
509–26, https://doi.org/10.1080/16506073.2021.1939410.

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opportunity for young adults to escape into therapeutic virtual environments, where they can
engage in immersive activities that promote relaxation, mindfulness, and emotional selfregulation. A recent study demonstrated that employing emotion-focused therapy within a VR
enrichment experience, which involves a three-step process of Emotion Awareness, Emotion
Regulation, and Emotion Transformation, shows the potential to revolutionize digital-age mental
therapy14.
14 Daniela Villani, Alessandra Preziosa, and Giuseppe Riva, “Coping with Stress Using Virtual Reality: A New
Perspective.,” Annual Review of CyberTherapy and Telemedicine 4 (2006): 25–32.

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Chapter 2: Therapeutic Principles and Practices Incorporated into
Game Design
Therapeutic principles and practices have the potential to be integrated into the realm of
game design. Cognitive Behavioral Therapy (CBT)15 stands as a foundation for understanding
the intricate connections between thoughts, emotions, and behaviors. The first section focuses on
the transformative power of positive imagery and how it can be effectively employed in digital
interventions and games to promote mental well-being. Self-counseling through Virtual Body
Ownership16, as explored in the second section, represents a dynamic tool for emotional
regulation. Through immersive virtual scenarios, individuals can engage in extended dialogues
with themselves, effectively addressing personal issues and improving mood and happiness
levels. Meditation and Mindfulness-Based Cognitive Therapy17 are highlighted as versatile
techniques for fostering well-being. Furthermore, the studies of contemporary art and music
therapy showcase how interactive experiences and immersive technologies can elevate these
therapeutic practices. Lastly, an important consideration is exploring the growing field of
ecopsychology18 and highlighting its connection to Eastern philosophies such as Yin-Yang19 and
the Five Elements20. These three areas underscore the profound interrelationship between human
psychology and the natural environment.
15 Aaron T. Beck, “Cognitive Therapy: Nature and Relation to Behavior Therapy,” Behavior Therapy 1, no. 2 (May
1970): 184–200, https://doi.org/10.1016/S0005-7894(70)80030-2. 16 Sofia Adelaide Osimo et al., “Conversations between Self and Self as Sigmund Freud—A Virtual Body
Ownership Paradigm for Self Counselling,”Scientific Reports 5, no. 1 (September 10, 2015): 13899,
https://doi.org/10.1038/srep13899.
17 Walter E B Sipe and Stuart J Eisendrath, “Mindfulness-Based Cognitive Therapy: Theory and Practice,” The
Canadian Journal of Psychiatry 57, no. 2 (February 2012): 63–69, https://doi.org/10.1177/070674371205700202. 18 Peter H. Kahn (Jr.) and Patricia H. Hasbach, Ecopsychology: Science, Totems, and the Technological Species
(MIT Press, 2012).
19 The I Ching or Book of Changes (Princeton University Press, 2011). 20 Donald M. Pachuta, “Chinese Medicine: The Law of Five Elements,” India International Centre Quarterly 18, no.
2/3 (1991): 41–68.

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2.1 Positive Imagery in Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT), developed by Dr. Aaron T. Beck in the 1960s, is a
foundational and widely acknowledged therapeutic approach to address mental health concerns.
CBT operates on the premise that thoughts, emotions, and behaviors are interconnected, altering
negative thought patterns and driving positive emotional and behavioral outcomes21. Central to
CBT is identifying and challenging negative thought patterns and beliefs, a process known as
cognitive restructuring, where irrational or distressing thoughts are supplanted by more balanced
and adaptive alternatives22. This cognitive aspect of CBT complements behavioral strategies,
including gradual exposure to feared situations with the application of new coping mechanisms.
The effectiveness of CBT in mitigating a range of mental health disorders is extensively
documented. It has consistently demonstrated its efficacy in alleviating symptoms of conditions
such as anxiety, depression, and post-traumatic stress disorder (PTSD), among others23.
One of the essential techniques within the Cognitive Behavioral Therapy (CBT)
framework is Positive Imagery. It involves guiding individuals to vividly imagine positive
scenarios, places, or outcomes so that they can effectively leverage the mind's capacity to
influence their emotions. In traditional therapy settings, positive imagery techniques are utilized
to alleviate a range of psychological challenges, from managing anxiety to enhancing self-esteem
and resilience24.
21 Aaron T. Beck, “Cognitive Therapy: Nature and Relation to Behavior Therapy,” Behavior Therapy 1, no. 2 (May
1970): 184–200, https://doi.org/10.1016/S0005-7894(70)80030-2.
22 Aaron T. Beck and David J.A. Dozois, “Cognitive Therapy: Current Status and Future Directions,” Annual
Review of Medicine 62, no. 1 (February 18, 2011): 397–409, https://doi.org/10.1146/annurev-med-052209-100032.
23 Stefan G. Hofmann et al., “The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-Analyses,”
Cognitive Therapy and Research 36, no. 5 (October 2012): 427–40, https://doi.org/10.1007/s10608-012-9476-1.
24 Simon E. Blackwell et al., “Positive Imagery-Based Cognitive Bias Modification as a Web-Based Treatment Tool
for Depressed Adults: A Randomized Controlled Trial,” Clinical Psychological Science 3, no. 1 (January 2015): 91–
111, https://doi.org/10.1177/2167702614560746.

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Studies reveal two distinct approaches to applying positive imagery: Direct and Indirect.
Direct techniques involve the transformation of intrusive negative imagery into positive ones,
employing methods like imaginal exposure and memory rescripting to evoke new emotions and
foster growth. In contrast, indirect techniques center on reshaping one's perception of mental
imagery itself, encouraging a more abstract view and emphasizing that these images represent
thoughts rather than reality. These approaches utilize strategies like meta-cognition and cognitive
tasks to disrupt problematic imagery and modify cognitive biases25.
Figure 2: Screenshot of SPARX 2 gameplay. SPARX. Inside the world of SPARX 2. YouTube.
YouTube, 2022. https://www.youtube.com/watch?v=m14cH0hPoMU.
Numerous digital interventions and games have successfully incorporated positive
imagery to promote mental well-being. For instance, SPARX, a game designed for adolescents
25 Emily A. Holmes, Arnoud Arntz, and Mervin R. Smucker, “Imagery Rescripting in Cognitive Behaviour
Therapy: Images, Treatment Techniques and Outcomes,” Journal of Behavior Therapy and Experimental Psychiatry
38, no. 4 (December 2007): 297–305, https://doi.org/10.1016/j.jbtep.2007.10.007.

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dealing with depression, integrates positive imagery and metaphors to encourage players to
overcome negative thoughts (See Figure 2). Research has shown that SPARX is effective in
reducing depressive symptoms26. This example highlights the versatility of positive imagery in
game design and its capacity to foster emotional well-being.
2.2 Self-counseling through Virtual Body Ownership
Self-counseling emerges as another compelling therapeutic tool representing a userdriven approach to emotional regulation. It empowers individuals to actively engage in
introspective processes that let them navigate the complex terrain of their thoughts and emotions.
Self-counseling techniques encompass a diverse array of strategies. From guided self-reflection
exercises to interactive decision-making scenarios, these immersive and interactive experiences
foster self-awareness and self-regulation.
26 S. N. Merry et al., “The Effectiveness of SPARX, a Computerised Self Help Intervention for Adolescents Seeking
Help for Depression: Randomised Controlled Non-Inferiority Trial,” BMJ 344, no. apr18 3 (April 19, 2012): e2598–
e2598, https://doi.org/10.1136/bmj.e2598.

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Figure 3: The Counseling Scenario. Sofia Adelaide Osimo et al., “Conversations between
Self and Self as Sigmund Freud—A Virtual Body Ownership Paradigm for Self
Counselling,” Scientific Reports 5, no. 1 (September 10, 2015): 13899,
https://doi.org/10.1038/srep13899.
(A) Stereo 1PP view from the participant in his lookalike body, looking towards the
Freud counselor. He sees himself from 1PP and also in the mirror to his left.
(B) Stereo 1PP view from the Freud body looking towards the lookalike representation
of the participant. He sees himself as Freud from 1PP and also in the mirror to his right.
Readers may fuse the two images in each of (A,B) into one stereo image by crossing their
eyes.
(C) The participant with the HMD and the motion capture suit. Note how the posture is
reflected in (A) through the motion capture.
(D) The participant being scanned to make his lookalike body.

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In the study conducted by Sofia Adelaide Osimo et al., the participants embodied two
distinct virtual bodies (See Figure 2), allowing them to engage in an extended dialogue with
themselves. Within this virtual scenario, one embodiment represented the participants
themselves, while the other embodied a counselor. This setup facilitated conversations in which
participants discussed personal issues with the counselor embodiment. In one experimental
condition, the counselor's embodiment resembled Dr. Sigmund Freud, while in another
condition, it looked like the participant. According to the report, self-counseling achieved by
both virtual body ownership improves mood and happiness levels, with the first condition (the
Dr. Sigmund Freud condition) being more effective27. This phenomenon is due to the illusion of
owning a body distinct from our own, which influences our perceptions, attitudes, behaviors, and
self-identity28.
2.3 Meditation and Mindfulness-Based Cognitive Therapy
Rooted in centuries-old traditions, meditation is considered a versatile technique in the
realm of therapeutic practices. Meditation is not merely an esoteric exercise but a practical tool
with many benefits that span the physical, psychological, and spiritual domains. Its practice is
linked to reduced stress, improved concentration, better sleep patterns, and effective pain
management29.
27 Sofia Adelaide Osimo et al., “Conversations between Self and Self as Sigmund Freud—A Virtual Body
Ownership Paradigm for Self Counselling,” Scientific Reports 5, no. 1 (September 10, 2015): 13899,
https://doi.org/10.1038/srep13899.
28 Lara Maister et al., “Changing Bodies Changes Minds: Owning Another Body Affects Social Cognition,” Trends
in Cognitive Sciences 19, no. 1 (January 2015): 6–12, https://doi.org/10.1016/j.tics.2014.11.001.
29 Bassam Khoury et al., “Mindfulness-Based Therapy: A Comprehensive Meta-Analysis,” Clinical Psychology
Review 33, no. 6 (August 2013): 763–71, https://doi.org/10.1016/j.cpr.2013.05.005.

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MBCT, or Mindfulness-Based Cognitive Therapy, incorporates meditation as a
fundamental component of its program. MBCT typically comprises eight weekly sessions,
encompassing formal and informal meditation practices, with an increasing focus on independent
meditation and expanding mindfulness to mental events, thoughts, and emotions. It includes
guided body scans, meditation practices, yoga-based mindful movements, and focused awareness
of daily activities. Early sessions concentrate on guided meditations for breathing and bodily
sensations, while later sessions encourage independent practice and mindfulness in dealing with
thoughts and emotions previously avoided30.
Figure 4: Screenshot of TRIPP gameplay. TRIPP, LLC. TRIPP® PlayStation Store Cover.
PlayStation Store. Sony, November 30, 2020. https://store.playstation.com/enus/product/UP5956-CUSA25147_00-9550879995002358.
30 Walter E B Sipe and Stuart J Eisendrath, “Mindfulness-Based Cognitive Therapy: Theory and Practice,” The
Canadian Journal of Psychiatry 57, no. 2 (February 2012): 63–69, https://doi.org/10.1177/070674371205700202.

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Meditation seamlessly integrates into modern therapeutic approaches as outcomes further
develop in the digital age. One of the innovative avenues is the convergence of meditation and
Virtual Reality (VR) technology. VR offers an environment where meditation transcends
conventional boundaries. VR meditation experiences are designed to transport individuals to
serene and visually captivating settings, enhancing the depth and impact of their practice (See
Figure 4). Through the incorporation of VR technology, practitioners can escape into meditative
realms that evoke a profound sense of presence and tranquility. Preliminary studies suggest that
VR meditation experiences can lead to enhanced relaxation, less distraction, and fatigue
compared to 2D format31.
2.4 Art and Music Therapy
Art therapy has long been recognized as a valuable tool for promoting mental well-being
and emotional expression. Art therapy relies on the creative processes to facilitate emotional
exploration and self-awareness. Traditional applications of art therapy have proven beneficial in
managing stress, anxiety, and other mental health concerns32. In the digital era, this approach is
implemented in various ways, such as encouraging users to create digital artwork or engage with
interactive installations that adapt to their emotional states. For example, in a recent pilot study
(See Figure 5), the participants engaged in free-form immersive VR artmaking reported positive
emotions towards the creative process of both play and exploration33. With the advent of virtual
31 Madison Waller et al., “Meditating in Virtual Reality 3: 360° Video of Perceptual Presence of Instructor,”
Mindfulness 12, no. 6 (June 2021): 1424–37, https://doi.org/10.1007/s12671-021-01612-w.
32 Annemarie Abbing et al., “The Effectiveness of Art Therapy for Anxiety in Adults: A Systematic Review of
Randomised and Non-Randomised Controlled Trials,” ed. Vance W. Berger, PLOS ONE 13, no. 12 (December 17,
2018): e0208716, https://doi.org/10.1371/journal.pone.0208716.
33 Girija Kaimal et al., “Virtual Reality in Art Therapy: A Pilot Qualitative Study of the Novel Medium and
Implications for Practice,” Art Therapy 37, no. 1 (January 2, 2020): 16–24,
https://doi.org/10.1080/07421656.2019.1659662.

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and augmented reality, the potential for even more immersive and emotionally engaging
experiences is on the horizon.
Figure 5: Setup for Creative Expression in Virtual Reality. Girija Kaimal et al., “Virtual
Reality in Art Therapy: A Pilot Qualitative Study of the Novel Medium and Implications for
Practice,”Art Therapy 37, no. 1 (January 2, 2020): 16–24,
https://doi.org/10.1080/07421656.2019.1659662.
Music therapy, on the other hand, leverages the capacity of music to evoke emotions and
influence mood. According to research, music benefits health through neurochemical changes in
reward, motivation, pleasure, stress, arousal, immunity, and social affiliation34. Recently, a new
34 Mona Lisa Chanda and Daniel J. Levitin, “The Neurochemistry of Music,” Trends in Cognitive Sciences 17, no. 4
(April 2013): 179–93, https://doi.org/10.1016/j.tics.2013.02.007.

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model, “Guided Imagery and Music (GIM),” was developed to further enhance the healing
power of music in mental health therapy. The GIM intervention process involves structured
music listening sessions, guided relaxation, heightened body awareness, addressing symptoms
and pain, rebalancing the nervous system, and embodying mental imagery experienced during
the music sessions. The same study also demonstrated a significant reduction in both biological
and psychological stress symptoms after nine weeks of GIM treatment35.
2.5 Ecopsychology and Eastern Beliefs in Yin-Yang and Five Elements
Ecopsychology36, a growing discipline in Western psychology, explores the link between
human psychology and the natural world. In Eastern philosophy, two fundamental concepts, YinYang37 and the Five Elements38, have also played a significant role in understanding nature,
health, and the human mind.
In Ecopsychology theories, human behavior, thoughts, and feelings are intricately linked
to their physical bodies, which play a crucial role in interacting with the surrounding
environment. These interactions include the generation of electric and magnetic fields as ions
move through cell walls during bodily processes, extending beyond the body's physical
boundaries. These fields not only affect other organisms in proximity but also make humans
sensitive to changes in the electric and magnetic field environment around them39. This concept
35 Bolette Daniels Beck, Åse Marie Hansen, and Christian Gold, “Coping with Work-Related Stress through Guided
Imagery and Music (GIM): Randomized Controlled Trial,” Journal of Music Therapy 52, no. 3 (2015): 323–52,
https://doi.org/10.1093/jmt/thv011.
36 Kahn (Jr.) and Hasbach, Ecopsychology. 37 The I Ching or Book of Changes. 38 Pachuta, “Chinese Medicine.” 39 Paul Stevens, “Embedment in the Environment: A New Paradigm for Well-Being?,” Perspectives in Public
Health 130, no. 6 (November 2010): 265–69, https://doi.org/10.1177/1757913910384047.

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of nature embodiment and embedment challenges the traditional view of humans as isolated
entities and underscores the profound relationship between individuals and their surroundings.
In the concept of Yin and Yang, nature is governed by the duality of Yin, the feminine,
dark, and passive force, and Yang, the masculine, light, and active force. This duality is not
confined to nature but is mirrored in human psychology. It accentuates the intricate dance
between opposing yet complementary forces, akin to the ever-shifting dynamics of the
environment. In the doctrine of the Five Elements —Wood, Fire, Earth, Metal, and Water —each
element is associated with various aspects of nature and human experiences. Wood symbolizes
growth and expansion; Fire embodies transformation and passion; Earth represents stability and
nurturing; Metal conveys purification and clarity, while Water signifies adaptability and the ebb
and flow of life. The dynamic interactions of these elements within nature, such as water
nourishing wood and wood nourishing fire, while fire is restrained by water, reveal a profound
connection between yin and yang40.
Eastern astrology, particularly the system of the Eight Characters, is deeply intertwined
with the foundational principles of Yin-Yang and the Five Elements. The Eight Characters, also
known as BaZi in Chinese, is a form of astrological divination that assesses an individual's
destiny and character based on their birth date and time. Eight Characters combines these
principles to create a comprehensive profile of an individual, offering insights into their
strengths, weaknesses, and life path. Understanding the interactions between the Eight
Characters, Yin-Yang, and the Five Elements enables individuals to make informed decisions,
navigate challenges, and harmonize their lives with the natural world. This holistic approach to
astrology reflects the deep-rooted connection between humans and the broader universe. While
40 Kazuya Hara, “Application of Yin and Yang and the Five Elements in Self- Counseling: An Intrapersonal
Communication Perspective in Japan,” 2018.

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there is limited scientific evidence supporting the efficacy of the Eastern astrological system, it
has persisted as a revered tradition with thousands of years of practice.

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Chapter 3: Case Studies of Existing Products
This chapter presents an in-depth examination of three games that have particularly
captured my attention in the field that intersects mental health and gaming: Nevermind, a
biofeedback thriller; TRIPP, a VR meditation experience; and Blowing Blues, an experimental
health game. Nevermind integrates biofeedback and adapts gameplay based on stress levels.
TRIPP employs psychedelic imagery to steer users through mindfulness exercises in VR.
Blowing Blues, an experimental project, uses breath control for stress relief. Despite their
limitations, these games inspire my VR game design process to emphasize environmental design,
guided mindfulness activities, and personalization for heightened mind-body connection and
emotional engagement.
3.1 Nevermind

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Figure 6: Screenshot of Nevermind gameplay showing biofeedback in action. Nevermind
Steam Store page. Sep 29, 2015. https://store.steampowered.com/app/342260/Nevermind/.
Nevermind41 is a pioneering biofeedback-enhanced adventure thriller game designed to
immerse players in the intricate and enigmatic realms of the subconscious mind. Initially
developed by Erin Reynolds and commercialized by Flying Mollusk, this game stands at the
intersection of gaming, psychological exploration, and biofeedback technology. What sets this
game apart is its integration of biofeedback technology, where players wear a heart rate monitor.
The game responds to the player's stress levels, intensifying challenges and altering the narrative
based on the detected psychological state. Incorporating biofeedback not only entertains but also
serves as a tool for self-reflection and stress management. Players are prompted to regulate their
emotions consciously, creating a potential avenue for emotional resilience and self-awareness.
While the integration of biofeedback was groundbreaking at that time, potential challenges
included the need for reliable heart rate monitoring and the general adaptability of players to this
novel gaming experience. Some players might find the constant adjustments based on stress
levels challenging, raising questions about the balance between challenge and frustration.
Another comparable product, DEEP42, a biofeedback VR game that teaches
diaphragmatic breathing, has demonstrated its potential for stress reduction. What can be learned
from this kind of game is the emotional stimulation facilitated by the environmental rendering. In
the initial stages of Breathing Out, I also create a tense atmosphere through the context of the
environment and sound effects to enhance the player's emotional immersion.
41 Erin Reynolds, “Nevermind: Creating an Entertaining Biofeedback-Enhanced Game Experience to Train Users in
Stress Management,” in ACM SIGGRAPH 2013 Posters (SIGGRAPH ’13: Special Interest Group on Computer
Graphics and Interactive Techniques Conference, Anaheim California: ACM, 2013), 1–1,
https://doi.org/10.1145/2503385.2503469.
42 Lisa Klein Haneveld et al., “Exploring the Added Value of Virtual Reality Biofeedback Game DEEP in Forensic
Psychiatric Inpatient Care—A Qualitative Study,” Frontiers in Psychology 14 (November 9, 2023): 1201485,
https://doi.org/10.3389/fpsyg.2023.1201485.

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3.2 TRIPP
TRIPP is an innovative entry into virtual reality (VR) meditation games, aiming to
elevate mental wellness through immersive technology. The game employs captivating
psychedelic imagery, a departure from traditional meditation applications, to guide users through
mindfulness exercises. Players navigate visually stimulating environments that foster a sense of
presence and engagement. The immersive nature of the game aids in stress reduction and
relaxation43. The combination of VR and psychedelic visuals is designed to induce a calming
effect, providing users with a unique avenue for achieving mindfulness and emotional balance.
Players’ experiences with TRIPP vary, with many praising its ability to transport them to serene
and visually engaging landscapes. The game's psychedelic visuals (see Figure 4) may enhance
the meditation experience for some. However, individual preferences play a significant role, and
not all users resonate with the psychedelic approach.
VR mindfulness tools like TRIPP may provide a stronger sense of immersion for players
compared to 2D meditative videos. However, I prefer not to practice mindfulness in a way that
separates people from the real world. The psychedelic imagery in TRIPP, while vibrant, is far
from the real world. My question is whether establishing a connection with the psychedelic
virtual world can teach people to deal with negative emotions in real life. However, what can be
learned from this game is how it guides players to establish a connection between body and mind
through breathing techniques and visual presentation. In Breathing Out, I adopt a more
minimalistic artistic expression to achieve this.
43 Costina-Ruxandra Poetar, Nathan Bradley, and Alexandra Voinescu, “Immersive Virtual Reality or Computerised
Mindfulness Meditation for Improving Mood? Preliminary Efficacy from a Pilot Randomised Trial,” Frontiers in
Psychology 14 (October 25, 2023): 1157469, https://doi.org/10.3389/fpsyg.2023.1157469.

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3.3 Blowing Blues
Figure 7: Screenshot of Blowing Blues Gameplay. Image from Xuan Liu. 2013.
https://mbf.blogs.com/.a/6a00d83451ba1e69e20192abe92003970d-popup.
Blowing Blues44, designed and developed by Xuan Li, is an interdisciplinary health game
and intervention that explores relaxation breathing, stress coping, and emotion management.
Blowing Blues employs a distinctive approach by utilizing the player's breath as a controller for
relaxation breathing. Players first input personalized descriptions of negative emotions, which
are then transformed into targets for breath-controlled elimination. The game contributes to
players' emotion regulation skills through interactive and visually reinforced experiences.
Different from the previous two products, Blowing Blues is a smaller-scale experimental
project rather than a commercial production like TRIPP, yet its concept captivates my interest.
44 Xuan Li, “Blowing Blues: Coping with Negative Emotions through Breath Control,” University of Southern
California Digital Library, April 28, 2015, https://doi.org/10.25549/usctheses-c3-246777.

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The integration of breath as a controller in mindfulness meditation practices reminds me of
traditional medicine concepts like QiGong45. What truly inspires me is the level of
personalization it offers. When players can input their feelings and witness them evolve with
their breath, their experience feels more profound. Breathing Out aims to elevate this
personalization to another level by leveraging the immersive characteristics of VR. This enables
players to engage with their emotions more deeply, enhancing the overall interactive
experience46.
45 “Qigong: What You Need To Know,” NCCIH, accessed March 16, 2024,
https://www.nccih.nih.gov/health/qigong-what-you-need-to-know. 46 Jeffery A. Newell, “The Emotional and Therapeutic Impact of Video Games for Health: Is Motivation to Improve
More Important Than Expectations for Improvement?” (M.A.), accessed March 16, 2024,
https://www.proquest.com/docview/2155338443/abstract/E47A886AEAF44A7FPQ/1.

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Chapter 4: Developing Breathing Out – A Therapeutic VR
Experience
This chapter unfolds the intricacies of level design, visual and audio aesthetics, narrative
composition, and the interactive experience that collectively shapes this therapeutic virtual
reality experience. Each phase within the level design constructs a progressive narrative, from
fostering self-awareness to the symbolic release of emotions. Inspired by Monument Valley47’s
artistry, visual aesthetics create a dreamlike atmosphere. Audio elements inspired by nature
envelop players in a tranquil cocoon, enhancing the immersive quality. The storytelling
technique, employing a dialogue between the first and third-person perspectives, also functions
as a tutorial, seamlessly guiding players through the immersive experience. Lastly, the
interactive experience design, employing hand-tracking for a closer connection to reality, guides
players to adapt and understand mindful interactions.
4.1 Level Design
Phase I: Connection – I see myself.
47 “Monument Valley | Ustwo Games,” Monument Valley | ustwo Games, accessed March 16, 2024,
https://ustwogames.co.uk/monument-valley.

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Figure 8: Illustrated prototype for Breathing Out Phase I: Connection. Tianxi Ren (November
27, 2023)
Breathing Out starts with choosing a low-poly character that resembles the player. The
emphasis on maximizing the morphological similarity between the player's biological body and
their virtual representation enhances the perception of ownership and embodiment of the virtual
body48. When the player selects their character, their bodily movements are continuously
synchronized with the avatar represented in the mirror. Research suggests that the real-time
mapping of body movement to the virtual character can create a compelling illusion, enhancing
the player's sense of ownership and connection with their in-game representation49. This mirror
48 Konstantina Kilteni, Raphaela Groten, and Mel Slater, “The Sense of Embodiment in Virtual Reality,” Presence:
Teleoperators and Virtual Environments 21, no. 4 (November 2012): 373–87,
https://doi.org/10.1162/PRES_a_00124.
49 Mel Slater, “Inducing Illusory Ownership of a Virtual Body,” Frontiers in Neuroscience 3, no. 2 (September 15,
2009): 214–20, https://doi.org/10.3389/neuro.01.029.2009.

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interaction serves as a pivotal moment that deepens the bond between players and their
characters.
After the player has selected their character, they are prompted with questions, such as,
“What do you think triggers anxiety in you?” through both audio and visual elements. These
questions aim to understand the player's negative emotions and some of the underlying causes,
which will be integrated into a personalized narrative later in the game. During this period, the
player remains facing the mirror, allowing their subtle, inadvertent movements to be reflected in
the mirror as the individual contemplates the questions in order to reinforce the sense of
embodiment.
Phase II: Stimulation – I feel my emotions.
Figure 9: Illustrated prototype for Breathing Out Phase II: Stimulation. Tianxi Ren
(November 27, 2023)

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Upon entering this phase, the player finds oneself in an empty room with a locked door
but no windows. Then, the character starts to express distress about being trapped in a small
space. The player can explore the room and interact with the door, but they will find no way out.
The character appears increasingly anxious, with a passive speech of hopelessness, such as, “Oh,
what if I cannot get out and die here.”
According to the model proposed by Daniela Villani, Alessandra Preziosa, and Giuseppe
Riva, the initial phase of an effective therapeutic experience involves fostering the individual's
awareness of sensorimotor processes and promoting mindfulness of their internal experience50.
The design of environmental details in this phase, such as the pounding heartbeat, rapid breath
sounds, and ominous background music, serve to evoke emotions in the player.
Phase III: Labeling – I put my thoughts there.
50 Daniela Villani, Alessandra Preziosa, and Giuseppe Riva, “Coping with Stress Using Virtual Reality: A New
Perspective.,” Annual Review of CyberTherapy and Telemedicine 4 (2006): 25–32.

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Figure 10: Illustrated prototype for Breathing Out Phase III: Labeling. Tianxi Ren (November
27, 2023)
At the beginning of this phase, rain begins to fall from the sky, filling the room with
water. The decision to incorporate water as the central element of the experience draws
inspiration from traditional Chinese philosophical frameworks, specifically the Yin-Yang and the
Five Elements doctrines discussed earlier. In this context, water symbolizes emotions,
adaptability, and the flow of life. The player is guided to label their negative emotions to the
raindrops. This design is inspired by a mindful activity known as “Leaves on a Stream.” This
activity draws from the principles of Acceptance and Commitment Therapy (ACT)51, which aim
to assist individuals in perceiving and accepting their thoughts, particularly negative ones, and
then taking positive actions to cope with them. In the “Leaves on a Stream52” activity,
participants are initially required to take each thought entering their minds and place it on a leaf.
In Breathing Out, players place their emotions on raindrops instead.
Phase IV: Regulation – I float in my thoughts.
51 Steven C. Hayes, Kirk D. Strosahl, and Kelly G. Wilson, Acceptance and Commitment Therapy, Second Edition:
The Process and Practice of Mindful Change (Guilford Publications, 2016). 52 Russ Harris, ACT Made Simple: An Easy-to-Read Primer on Acceptance and Commitment Therapy (New
Harbinger Publications, 2009).

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Figure 11: Illustrated prototype for Breathing Out Phase IV: Regulation. Tianxi Ren
(November 27, 2023)
After a period of rain, the room becomes flooded. At this point, the player needs to
engage in guided breathing exercises to make the character float on the water. Accompanied by
the sounds of rain, music, and instructional cues, the player places both hands in front of one’s
chest, holding onto two raindrops, and gently moves them apart with the expansion of the chest
during inhalation, then slowly brings them together with the contraction of the chest during
exhalation. This action is repeated several times until mastery is achieved. As this is a guided
experience, the game provides various types of feedback tailored to different situations for
different players:
• Best case scenario: The player follows the voiceover instruction and performs the
breathing exercise accurately according to the rhythm. In this situation, the character

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soon calms down and says something like, “I feel much better now.” The water level
keeps rising, and the character floats on the surface of the water.
• Second best scenario: The player follows the voiceover instruction and performs the
breathing exercise according to the rhythm with more than 70% accuracy but not
perfectly. In this situation, the character struggles in the water for a while but
eventually calms down. The character says something like “(breath), That was close. I
saved myself.” The water level keeps rising, and the character will float on the
surface of the water. The session is longer than the best-case scenario.
• Third best scenario: The player follows the voiceover instruction and performs the
breathing exercise according to the rhythm with less than 70% accuracy but above
40%. In this situation, the character struggles in the water. While struggling, the
character says something like, “Keep it up. (breath). I just need a little more air.” The
water level stops rising, but the character keeps struggling until the player reaches
70% accuracy with additional voiceover instructions. The water level starts rising,
and the character floats on the surface of the water. The session is longer than the
second-best scenario.
• Worst case scenario: The player does not follow the voiceover instruction and
performs the breathing exercise according to the rhythm with less than 40% accuracy.
In this situation, the character struggles in the water for a while but eventually calms
down. The water level stops rising, and the character can stand in the water because it
is safe. Then the character says something like, “It stops! Actually, not a big deal. I
can do better!” Then, the player is prompted to do the breathing exercise again but
with both eyes closed and additional voice instruction. Before the exercise ends, the

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character says, “Look! I’m floating in the water! This is so cool.” And the player will
open both eyes. The session is much longer than the best-case scenario.
Phase V: Defusion – I let go of my thoughts.
Figure 12: Illustrated prototype for Breathing Out Phase V: Defusion. Tianxi Ren (November
27, 2023)
When the rainwater fills the entire room, the player completes the breathing activity. At
this point, the player switches to a bird's-eye perspective, observing the character peacefully
floating on the water. The character engages in self-reflection, summarizing some recent
experiences and insights, and then poses the question, “Now, how do I leave this room?” Then,
the instructional cues guide the player to pick up the room and pour the character out, just like
pouring water out of a container. This design is also inspired by the final step in “Leaves on a
Stream,” during which participants watch leaves that carry their emotions and thoughts floating

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away with the stream. Similarly, in Breathing Out, the player helps the character (the player)
escape the enclosed room by pouring out the water that carries emotions and thoughts. During
this process of self-redemption, the player realizes that obstacles can be leveraged as
opportunities for growth and development if approached with the appropriate mindset and
strategies.
Phase VI: Return – I am back.
Figure 13: Illustrated prototype for Breathing Out Phase VI: Return. Tianxi Ren (November
27, 2023)
After escaping the room, the scene undergoes a transformation. The player realizes the
character is actually inside an indoor swimming pool, able to hear conversations and footsteps.
Non-player characters (NPCs) approach the character with greetings like, “Are you okay? Is
there anything I can help you with?” The design of this transformation serves as a metaphor,

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illustrating that when individuals are overwhelmed by negative emotions, they may overlook the
people or environment around them. However, reality is not as horrible as imagined. At this
point, the level formally concludes.
4.2 Visual and Audio Design
Visual Design
Figure 14: Wallpaper for Monument Valley. Clyss, “Monument Valley – Darkness”,
Wallpaper Abyss (2016), https://wall.alphacoders.com/big.php?i=675024.
Inspired by the artistry of the game Monument Valley53, Breathing Out embraces a
delicate yet vibrant color scheme. Drawing influence from Japanese prints and minimalist
sculpture, using less saturated hues with varying brightness, aims to create a dreamlike
ambiance. This choice is pivotal as the game transitions between first-person and third-person
53 “Monument Valley | Ustwo Games.”

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perspectives, immersing players in a fairy-tale world. The intention is to construct an
environment that is visually pleasing and calming. For interactive elements like rain, the strategic
application of blue hues against the low saturation of other objects highlights their significance
and directs the player's attention to them.
The user interface is designed with visibility and accessibility in mind within the VR
environment. Striking a balance between unobtrusiveness and functionality, the UI elements
harmonize with the overall visual style. This sense of harmony enhances user experience without
disrupting the immersive quality of the virtual world.
Audio Design
The audio design draws inspiration from the tranquility of nature, integrating ambient
sounds such as rain to enhance the immersive quality of the VR experience. The gentle patter of
raindrops contributes to a sense of presence, enveloping players in an auditory cocoon that
complements the visual elements. Calming voiceovers guide players through the virtual journey,
creating a narrative thread that intertwines with the visual landscape. The aim is to enrich the
storytelling experience and establish an emotional connection between the user and the VR
environment. Minimalist yet purposeful audio cues respond to user interactions. Incorporating
bodily sounds, such as the heartbeat, heightens the player's awareness of the character's
emotional state, a crucial element for effective engagement with the subsequent breathing
exercises.

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4.3 Storytelling
The storytelling adopts a distinctive approach, weaving a dialogue between the firstperson and third-person perspectives. This narrative dynamic unfolds a series of interconnected
stories shaped by a player's choices during Phase I: Connection. Beyond traditional storytelling,
the narrative also serves as a tutorial, seamlessly guiding the player through interactive features
like the breathing exercise. The adaptive narratives respond to player agency, creating a
personalized and interactive storytelling landscape.
4.4 Interactive Experience Design
The entire game is a guided experience, ensuring that a player cannot fail. This approach
allows the player ample time to interact with the environment until one adapts to these
interactions and understands the underlying meanings. The game utilizes a hand-tracking system
instead of a controller to simulate reality as closely as possible and establish a connection
between the player and real-life experiences. Each interaction serves a specific purpose:
facilitating emotional understanding, simulating breathing exercises, or providing a means for
progression within the game. By incorporating these diverse interactions, the game aims to offer
a comprehensive and engaging therapeutic experience. There are four main interactions in the
game:
Grab and Drop:
In Phase III: Labeling, players grasp 3D models representing emotional words suspended
in the air and place them in the rain, watching as they flow away with the water. This interaction
is designed to help players better comprehend the process of "labeling" emotions.
Pinch and Drag:

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In Phase IV: Regulation, the player engages in a breathing exercise. The player uses both
hands to pinch two UI elements and follow rhythmic prompts to contract (drag two UI elements
to meet in the center) and expand (drag two UI elements apart). This design simulates the
contraction and expansion of the chest during breathing and uses hand movements to assist in the
process.
Pinch and Switch Perspective:
At certain moments in the game, a player uses a pinch gesture with both hands to
seamlessly switch between the first-person and third-person perspectives. This interaction is
designed to simulate the gesture of reaching out for help, a symbolic act of extending both hands.
However, in this game, the player is seeking assistance not from others but from different
perspectives of oneself. This unique design aims to cultivate the player's ability for selfredemption, presenting a metaphorical journey of seeking support within one's own varied
viewpoints.
Grab and Pour:
In Phase V: Defusion, the player holds the container and pours out the water,
accompanied by the small avatar. Building on the groundwork laid in previous phases, the water
inside the container now carries complex emotions for the player. The design of this pouring
action allows the player to experience the sensation of pouring out "negative emotions" firsthand.
This design aims to create a visceral connection between the player and the symbolic act of
releasing emotional burdens, adding a profound layer to the gameplay experience.

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Chapter 5: Conclusion
This chapter concludes the thesis project by summarizing outcomes and proposing
avenues for future research. By exploring the application of interactive media in mental health
practices, this study sets the stage for further investigations into this evolving and impactful field.
5.1 Conclusion
In conclusion, this thesis confronts the escalating challenges of stress and anxiety among
young adults through the lens of games and storytelling, particularly within virtual reality.
"Breathing Out," a VR experience, emerges as an innovative solution by intertwining problemsolving, positive imagery, and guided meditation. Grounded in research and insights from mental
health professionals, this project seeks to equip young adults with practical coping mechanisms.
It stands as a personal design initiative, leveraging interactive media to educate and elevate
individuals, contributing to the evolving landscape of mental health interventions by
emphasizing the transformative potential of technology in personal well-being.
5.2 Suggested Future Research
This research has laid the groundwork for several potential avenues of investigation that
may benefit from further exploration. Given the rapid advancements in mixed reality technology,
future studies may employ more sophisticated tools, such as heart rate/metabolic rate monitors
and smell diffusion, to enhance the biofeedback in the immersive experience, thereby providing
more insights into how immersive storytelling can assist young adults in recognizing and coping
with anxiety and stress.
This game only explores the theme of water. However, there is considerable merit in

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investigating other themes within the Five Elements framework and examining their effects on
diverse individuals. According to the principles of Bazi, as mentioned earlier, individuals have
varying preferences for the five elements. Therefore, future research could explore these
additional themes and their potential impacts on individuals.

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Asset Metadata

Creator Ren, Tianxi (author)

Core Title Breathing out: a therapeutic virtual reality experience

School Roski School of Art and Design

Degree Master of Fine Arts

Degree Program Design

Degree Conferral Date 2024-05

Publication Date 04/03/2024

Defense Date 04/01/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag Anxiety,game,interaction design,Meditation,Mental Health,OAI-PMH Harvest,Stress,therapeutic experiences,virtual reality

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Gotsis, Marientina (committee chair), Burruss, Laurie (committee member), Greiman, April (committee member), Lemgruber, Bruno (committee member)

Creator Email tianxire@usc.edu,tianxiren9110@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113865293

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Format theses (aat)

Rights Ren, Tianxi

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