Bloom’s taxonomy and psychotherapeutic games

Bloom’s Revised Taxonomy has already been considered as the “most popular cognitive approach to Serious Game evaluation” [1]. Bloom’s original taxonomy [2] stems from the field of education and consisted of categories for Knowledge, Comprehension, Application, Analysis, Synthesis, and Evaluation. Bloom’s original taxonomy was a popular tool for objectives-based evaluation as it allowed for a high level of detail when stating learning objectives [3].

However, the original taxonomy was criticized resulting in various revisions by different authors. See de Kock, Sleegers, and Voeten for a classification of learning environments, containing reviews of the revisions [4]. The revision of Anderson et al. [5] as well as Pintrich [6] improves the original taxonomy by including the category of metacognition. They also distinguish between two dimensions: a Knowledge dimension and a Cognitive Process dimension.

We feel the inclusion of the metacognition knowledge level reflects the ongoing insight in the field of psychotherapy where Cognitive Behavioural Therapy (CBT) is currently advancing into its “third wave.” The first wave of CBT started in the 1950s and applied classical conditioning and operant learning. The second wave applied information processing and brought CBT to its current worldwide status. Now, a third wave of psychotherapies is developing “a heterogeneous group of treatments, including acceptance and commitment treatment, behavioural activation, cognitive behavioural analysis system of psychotherapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema therapy” [7]. These three waves in CBT can be seen to move up along both dimensions of our taxonomy. Different therapy forms in CBT’s third wave are aimed at the metacognitive level and include all the cognitive processing steps up to and including Creation as part of their treatment.

By applying Bloom’s Revised Taxonomy to analyze the content of psychotherapeutic games, we are approaching these games as educational content. We see all therapeutic interaction as part of a learning process; often knowledge is to be acquired, emotions are revised, and behaviour is changed during psychotherapy.

This is an excerpt of the paper I co-authored Using the Revised Bloom Taxonomy to Analyze Psychotherapeutic Games


1A. De Gloria, F. Bellotti, and R. Berta, “Serious Games for education and training,” International Journal of Serious Games, vol. 1, no. 1, 2014.View at: Google Scholar

2. B. S. Bloom, M. D. Engelhart, E. J. Furst et al., Taxonomy of educational objectives: Handbook I: Cognitive domain, vol. 56(19), 1956.

3. J. Marzano and S. Kendall, “The need for a revision of Blooms taxonomy,” in The New Taxonomy of Educational Objectives, Chapter: 1, pp. 1–20, Corwin Press, 2006.View at: Google Scholar

4. A. De Kock, P. Sleegers, and M. J. M. Voeten, “New learning and the classification of learning environments in secondary education,” Review of Educational Research, vol. 74, no. 2, pp. 141–170, 2004.View at: Publisher Site | Google Scholar

5. L. W. Anderson, D. R. Krathwohl, and B. S. Bloom, A taxonomy for learning, teaching, and assessing: A revision of Bloom’s taxonomy of educational objectives, Allyn & Bacon, 2001.

6. P. R. Pintrich, “The role of metacognitive knowledge in learning, teaching, and assessing,” Theory Into Practice, vol. 41, no. 4, pp. 219–225, 2002.View at: Publisher Site | Google Scholar

7. K. G. Kahl, L. Winter, and U. Schweiger, “The third wave of cognitive behavioural therapies: what is new and what is effective?” Current Opinion in Psychiatry, vol. 25, no. 6, pp. 522–528, 2012.View at: Publisher Site | Google Scholar

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The concept flourishing is based on optimal human functioning. It incorporates several constructs from the field of positive psychology.
In contrast to the commonly used hedonic approach of subjective well-being, flourishing is based on the eudaimonic approach of psychological well-being and involves some of the same constructs as self-efficacy from a mastery perspective. People reporting a higher sense of flourishing are also expected to score higher on self-efficacy. Higher self-esteem is also linked to higher levels of mastery and self-efficacy.

Flourishing Scale
The Flourishing Scale has eight items with answers given on a 7-point Likert scale from 1 strongly disagree to 7 strongly agree [Diener, 2009].

  1. I lead a purposeful and meaningful life
  2. My social relationships are supportive and rewarding
  3. I am engaged and interested in my daily activities
  4. I actively contribute to the happiness and well-being of others
  5. I am competent and capable in the activities that are important to me
  6. I am a good person and live a good life
  7. I am optimistic about my future
  8. People respect me

This scale was also used as part of the New Zealand’s Sovereign Well-Being Index (N=100,009). Subsequent analyses of the underlying structures and psychometric properties of the scales were performed as well as reliability and validity checks and benchmarking to other well-being scales used in the survey. The study concluded that the Flourishing Scale “is a valid and reliable brief summary measure of psychological functioning, suited for use with a wide range of age groups and applications ” [Hone, 2013].

In the data from my own experiment the Flourishing Scale (α=.90, mean 4.07 [SD 0.65]) correlates with other measurements of well-being (PANAS and self-esteem) as expected.

Keyes CLM. Flourishing. In: The Corsini Encyclopedia of Psychology. Hoboken, NJ: John Wiley and Sons; Jan 30, 2010.
Diener, E., Wirtz, D., Tov, W., Kim-Prieto, C., Choi, D., Oishi, S., & Biswas-Diener, R. (2009). New measures of well-being: Flourishing and positive and negative feelings. Social Indicators Research, 39, 247-266.
Diener E, Wirtz D, Biswas-diener R, Tov W, Kim-prieto C, Choi D, et al. New measures of well-being. In: Diener E, editor. Assessing Well-Being. Dordrecht, The Netherlands: Springer; 2009:247-266.
Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being.
Am Psychol 2000 Jan;55(1):68-78. [doi: 10.1037//0003-066x.55.1.68] [Medline: 11392867]
Lyubomirsky S, Tkach C, DiMatteo MR. What are the Differences between Happiness and Self-Esteem. Soc Indic Res
2005 Oct 04;78(3):363-404. [doi: 10.1007/s11205-005-0213-y]
Kardefelt-Winther D. The moderating role of psychosocial well-being on the relationship between escapism and excessive
online gaming. Computers in Human Behavior 2014 Sep;38:68-74. [doi: 10.1016/j.chb.2014.05.020]
Robins RW, Hendin HM, Trzesniewski KH. Measuring Global Self-Esteem: Construct Validation of a Single-Item Measure
and the Rosenberg Self-Esteem Scale. Pers Soc Psychol Bull 2016 Jul 02;27(2):151-161. [doi: 10.1177/0146167201272002]
Hone L, Jarden A, Schofield G. Psychometric Properties of the Flourishing Scale in a New Zealand Sample. Soc Indic Res
2013 Nov 6;119(2):1031-1045. [doi: 10.1007/s11205-013-0501-x]

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Games for Health

Health science has been embracing gaming as a meaningful way to communicate, educate, and as a mechanism to deliver treatment [1,2]. There has been a growing interest in both serious games for health and gamified health interventions [3], especially those concerning the treatment, rehabilitation, and management of chronic disease patients [4], as these games for health have shown potential for positive impact on health-behavior change.

Some research on the effectiveness of serious gaming for health promotion revealed an overall increase in healthy lifestyle adoption across several health domains [2] and that gameplay may induce a positive emotional experience and help facilitate satisfaction and self-esteem [4]. Effect sizes found on behavior after playing a serious game were small and comparable to the effect sizes of other computer-delivered interventions. Such effects of serious games for health were highest on knowledge outcomes, while smaller than expected on self-efficacy outcomes. Overall, the effectiveness of a health game was found to improve when game development had a theoretical foundation in behavioral prediction and game theories [5].

In order to create a full picture of the effectiveness of games for health, broader intervention characteristics should perhaps be evaluated, such as user experience and perceived relevance [6]. Some of the research into the effectiveness of games for health investigates the process during gameplay [7,8] while other research focuses on process after gameplay [5,9]. I would argue that the perceived appeal of any game for health belongs in this list of “broader intervention characteristics” and that measurements should also be made BEFORE gameplay.

excerpt of my paper The Effect of a Health Game Prompt on Self-efficacy: Online Between-Subjects Experimental Survey – freely available here


  1. Sharifzadeh N, Kharrazi H, Nazari E, Tabesh H, Edalati Khodabandeh M, Heidari S, et al. Health Education Serious Games Targeting Health Care Providers, Patients, and Public Health Users: Scoping Review. JMIR Serious Games 2020 Mar 05;8(1):e13459 [FREE Full text] [CrossRef] [Medline]

2. Kato PM. Video Games in Health Care: Closing the Gap. Review of General Psychology 2010 Jun;14(2):113-121. [CrossRef]

3. Johnson D, Deterding S, Kuhn K, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: A systematic review of the literature. Internet Interv 2016 Nov;6:89-106 [FREE Full text] [CrossRef] [Medline]

4. Sardi L, Idri A, Fernández-Alemán JL. A systematic review of gamification in e-Health. J Biomed Inform 2017 Dec;71:31-48 [FREE Full text] [CrossRef] [Medline]

5. DeSmet A, Van Ryckeghem D, Compernolle S, Baranowski T, Thompson D, Crombez G, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med 2014 Dec;69:95-107 [FREE Full text] [CrossRef] [Medline]

6. Verschueren S, Buffel C, Vander Stichele G. Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights. JMIR Serious Games 2019 May 02;7(2):e11565 [FREE Full text] [CrossRef] [Medline]

7. Brockmyer JH, Fox CM, Curtiss KA, McBroom E, Burkhart KM, Pidruzny JN. The development of the Game Engagement Questionnaire: A measure of engagement in video game-playing. Journal of Experimental Social Psychology 2009 Jul;45(4):624-634. [CrossRef]

8. Burgers C, Eden A, van Engelenburg MD, Buningh S. How feedback boosts motivation and play in a brain-training game. Computers in Human Behavior 2015 Jul;48:94-103. [CrossRef]

9. Garcia Pañella O. Game design and e-health: serious games put to the test. In: Advancing Cancer Education and Healthy Living in Our Communities (Putting Visions and Innovations into Action: Selected Papers from the St. Jude Cure4Kids® Global Summit 2011). Amsterdam, The Netherlands: IOS Press; 2012.

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Before the paper Effect of a Health Game Prompt

There are two stories here.
One is the story of the content of the paper and this is pretty straight forward. It started reading a paper and wondering about something:
…reading the work of Brooks, it seemed to me that prompting a game for health is also a call to be excited amidst anxious content and I wondered if a game for health might be considered arousal congruent cognitive reappraisal? If so, this perspective could help to explain some of the attraction to games for health and their effects on self-efficacy.
Diving into this question I found out more about cognitive reappraisal and self-efficacy and even found a diabetes specific self-efficacy scale (not in paper). I found more work and interesting examples of games for health and well-being. While investigating measurements for well-being I found a Flourishing scale. When I thought I had a good idea of the relevant concepts and their measures I formulated a simple online experiment. I ran it, analysed it and wrote up the process. It felt so good to throw my considerations at reality and collect data. I dipped my toes in the micro-task market by using MTurks. There was some struggling and getting to grips with mediation analysis. I was surprised – and initially very frustrated – by the answer to my overall question and am very grateful that I included a measure that might offer an explanation for these unexpected responses. The results offer a minute contribution to the better understanding of using games for health. Please read it and let me know what you think

Then there is a second story of the emotional context of this paper. This centres around a PhD that did not end well. When this paper was in a very early stage, I quit the PhD. This was a hard decision but I had lost all faith in ever getting to a positive ending and I still think it was the right decision. However, letting go of what I had been holding onto meant I fell down further.  Chronic pain, depression, physical therapy, mindfulness based cognitive behavioural therapy, a lovely psychologist at the pain clinic all followed each other. A process taking over two years. Starting during my PhD and ending long after.
And somewhere on my computer and nagging in the back of my mind was this paper. Sort of finished – but unpolished. Hours of my life already in it, the effort of all the people that had participated already in it and the method/experiment/result simple truths regardless. It’s not the ideas, the experiment or the correlations fault. What I love about science – and chase in effect research – is something that exists above, beyond and outside of me.
But every time I opened this document waves of emotion came with it. Even so, I returned to work on these pages. First this was a great smack in my face. None of the statistical analysis were clear in my mind and my ability to focus was shredded. This confrontation with a new me that could no longer understand the old me was horrible. Over time and a lot of emotions I re-read and re-did my own work until I re-understood. Then I tried to improve the paper.
Thankfully, I have some amazing friends. One is a health researcher and a data wizard, one is a statistician for social sciences and one is a games researcher. I worked on the pages until I thought they were good enough to be shown. My friends read it and returned it to me with comments. Normal comments that made it better – no fundamental flaws, nothing crazy. All three told me they thought it was about one-round-of-improvements away from trying to get it published. I took all their comments and made it better.
Now, there is almost four years in between me ending the PhD and me sending this paper in to be judged by JMIR Serious Games. The first year-and-a-half I didn’t touch it. Another year of painfully and sporadically confronting myself with myself and then a long time of working on it in between the rest of life. A life that has nothing to do with academia anymore. After submission, another year follows that includes a revise-and-resubmit, a global pandemic and an editor-switch before getting it published in my first-choice journal.
Five years and such a long emotional journey for such a small, simple paper. 

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Learning strategies and metacognition

In very broad strokes there are three kinds of learning strategies:
and organisational.

Rehearsal is the much used ‘rinse and repeat’ approach of content repetition or rote learning.
Elaboration might include the use of mnemonics, paraphrasing or summarizing content. These elaboration strategies lead to a deeper level of processing and better comprehension of the content as compared to rehearsal strategies (Pintrich, 2002).
Applying organizational strategies means connecting content elements by note-taking or, for example, creating a mind-map.

Metacognition is applied in the planning, monitoring and regulating of various learning strategies.  This metacognitive knowledge of different learning strategies and their (conditional) application seems to be involved determining the transfer of learning. ‘Transfer’ refers to the ability of using knowledge learned in one setting or situation, in another setting or situation (Bransford & Schwartz, 1999).

The demand of metacognition on working memory is two-fold:

  • The problem solving thoughts
  • Monitoring and regulating the thinking about the problem solving thoughts

In a teacher-student situation, the demand on working memory might be shared as the teacher offers cognitive resources for the actual problem solving or for the monitoring and regulating. This sharing of working memory resources is an application of distributed cognition (Schwartz et al., 2009).



Christoph, L. H. (2006). The role of metacognitive skills in learning to solve problems.

Weinstein, C. E., & Mayer, R. E. (1986). The teaching of learning strategies. Handbook of research on teaching, 3, 315-327

Pintrich, P. R. (2002). The role of metacognitive knowledge in learning, teaching, and assessing. Theory into practice, 41(4), 219-225

Bransford, J. D., & Schwartz, D. L. (1999). Rethinking transfer: A simple proposal with multiple implications. Review of research in education, 61-100

Schwartz, D. L., Chase, C., Chin, D. B., Oppezzo, M., Kwong, H., Okita, S., Wagster, J. (2009). Interactive metacognition: Monitoring and regulating a teachable agent. Handbook of metacognition in education, 340-358

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A Framework for developing Serious Games for Health

The paper Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights by Verschueren and colleagues provides a well-researched framework for developing any serious game and especially one for health/wellbeing purposes.

Their research into efficacy and best-practices in game development is poured into a framework with five stages

It all starts with asking the right questions, finding out what is relevant to your goals and preferable forming a hypothesis & thereby setting metrics, early on in development. Gather data from research, interviews and observation. Get your players, health care professionals and other stakeholders involved but not every step of the way begs the same kind of involvement. Test, iterate, test, iterate… and always keep your eyes on what you’ve determined as your goal and what was relevant to this. And finally, if you can, test your hypothesis.

I really recommend this paper – great read with good guidelines to follow!

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