A Gamified Mobile App That Helps People Develop the Metacognitive Skills to Cope With Stressful Situations and Difficult Emotions: Formative Assessment of the InsightApp
Authors: Amo Victoria , Prentice Mike , Lieder Falk 
Published: March 2023

Background
Ecological momentary interventions open up new and exciting possibilities for delivering mental health interventions and conducting research in real-life environments via smartphones. This makes designing psychotherapeutic ecological momentary interventions a promising step toward cost-effective and scalable digital solutions for improving mental health and understanding the effects and mechanisms of psychotherapy.

Objective
The first objective of this study was to formatively assess and improve the usability and efficacy of a gamified mobile app, the InsightApp, for helping people learn some of the metacognitive skills taught in cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based interventions. The app aims to help people constructively cope with stressful situations and difficult emotions in everyday life. The second objective of this study was to test the feasibility of using the InsightApp as a research tool for investigating the efficacy of psychological interventions and their underlying mechanisms.

Methods
We conducted 2 experiments. In experiment 1 (n=65; completion rate: 63/65, 97%), participants (mean age 27, SD 14.9; range 19-55 years; 41/60, 68% female) completed a single session with the InsightApp. The intervention effects on affect, belief endorsement, and propensity for action were measured immediately before and after the intervention. Experiment 2 (n=200; completion rate: 142/200, 71%) assessed the feasibility of conducting a randomized controlled trial using the InsightApp. We randomly assigned participants to an experimental or a control condition, and they interacted with the InsightApp for 2 weeks (mean age 37, SD 12.16; range 20-78 years; 78/142, 55% female). Experiment 2 included all the outcome measures of experiment 1 except for the self-reported propensity to engage in predefined adaptive and maladaptive behaviors. Both experiments included user experience surveys.

Results
In experiment 1, a single session with the app seemed to decrease participants’ emotional struggle, the intensity of their negative emotions, their endorsement of negative beliefs, and their self-reported propensity to engage in maladaptive coping behaviors (P<.001 in all cases; average effect size=−0.82). Conversely, participants’ endorsement of adaptive beliefs and their self-reported propensity to act in accordance with their values significantly increased (P<.001 in all cases; average effect size=0.48). Experiment 2 replicated the findings of experiment 1 (P<.001 in all cases; average effect size=0.55). Moreover, experiment 2 identified a critical obstacle to conducting a randomized controlled trial (ie, asymmetric attrition) and how it might be overcome. User experience surveys suggested that the app’s design is suitable for helping people apply psychotherapeutic techniques to cope with everyday stress and anxiety. User feedback provided valuable information on how to further improve app usability.

Conclusions
In this study, we tested the first prototype of the InsightApp. Our encouraging preliminary results show that it is worthwhile to continue developing the InsightApp and further evaluate it in a randomized controlled trial.