JMIR Publications

ABSTRACT

Background:

Alexithymia, characterized by difficulty identifying, describing, and expressing emotions, is prevalent among Chinese college students. Traditional art therapies face barriers such as high psychological thresholds and limited accessibility. Accessible, low-threshold digital tools are needed to help address this challenge. Coloring the Emoji, a coloring-based serious game designed as a digital art therapy, offers a low-threshold tool to support emotion regulation for this population.

Objective:

This study aimed to evaluate the effectiveness of Coloring the Emoji as a digital art therapy in improving alexithymia symptoms, examine the user experience of the game among Chinese college students, and provide empirical support for the application of coloring-based digital art therapy in alexithymia intervention.

Methods:

A mixed-methods design was employed, involving a 15-day daily game intervention with Chinese college students exhibiting alexithymic tendencies (TAS-20≥52). Participants were purposively recruited from a preliminary survey of 332 Chinese college students. Inclusion criteria were aged 18–30 years, able to use a smartphone, and no ongoing psychotherapy or psychiatric medication; those unable to complete game tasks were excluded. Twenty participants (45% male, 55% female; 40% undergraduates, 60% postgraduates) completed the full intervention. Quantitative assessments used the 20-item Toronto Alexithymia Scale (TAS-20) (pre- and post-test) to measure alexithymia and the Game Experience Questionnaire (GEQ) (post-test) to assess user experience. Statistical analyses comprised Wilcoxon signed-rank tests for pre-post comparisons, Mann-Whitney U tests for gender/education/major comparisons, and Kruskal-Wallis H tests for TAS-20 pretest severity comparisons. The qualitative component consisted of three semi-structured interviews (days 1, 8, and 15), analyzed using Colaizzi’s phenomenological method and thematic analysis to explore emotion regulation dynamics and user engagement.

Results:

Total TAS-20 scores decreased significantly post-intervention (pretest median 64.00, IQR 59.50-68.00; posttest median 60.50, IQR 55.80-64.30; Z=2.425, P=.015). The Difficulty Identifying Feelings (DIF) subscale showed a marginal trend toward significance (Z=1.826, P=.068). Demographic and baseline comparisons revealed that males achieved significantly greater DIF reductions (median 4.00, IQR 1.00-8.00 vs. females median 0.00, IQR -3.00 to 3.00; Z=-2.137, P=.033), while participants with severe baseline alexithymia showed the most progress in reducing Externally Oriented Thinking (EOT; median 3.00, IQR 2.00-6.00; H= 8.233, P=.016). GEQ scores reflected a positive experience, with the highest scores in Competence (median 2.85, IQR 2.48-3.20) and Sensory & Imaginative Immersion (median 2.80, IQR 2.05-3.28). Qualitative results revealed two major themes and ten subthemes; 75% (15/20) of participants reported enhanced emotional identification through the game.

Conclusions:

Coloring the Emoji is an effective, acceptable intervention for improving emotional identification in Chinese college students with alexithymia. It integrates color psychology and emotion models in a low-stress, de-medicalized format, addressing cultural preferences for cautious emotional disclosure. This study provides empirical support for coloring-based digital art therapy and offers a scalable, culturally adapted alternative to traditional mental health support for young adults. Clinical Trial: /