“Flowing” for Health

How health games help people get better


Robert Hone

2 years ago | 8 min read

Advanced software-based health treatments are offering new hope for people struggling with many chronic diseases and conditions such as ADHD, depression, diabetes, and anxiety.

Akili Interactive recently released their innovative Endeavor game-based treatment for ADHD (4/22/20)[1], while several other digital therapeutic (DTx) companies have health game projects under development. Your doctor may soon prescribe a therapeutic game to help you or your child confront a medical challenge.

The key element of these interactive programs is their ability to guide people into a tightly focused “flow” state where our sense of time fades way and tasks seem effortless. We’ve all probably experienced the flow state at one time or another in our lives. It could have been while running, skateboarding, surfing, or any one many athletic pursuits.

Or you may have entered this pleasant mental condition while singing, dancing, playing music, or other creative activities (even writing and design can produce flow).

Psychological researcher Mihaly Csikszentmihalyi coined the term “flow” to describe a satisfying, self-directed, hyper-focused state.

Our perceptions of our lives are the outcomes of many events that shape experience, each having an impact on whether we feel good or bad. Most of these forces are outside of our control. Yet we have all experienced time when, instead of being buffeted by anonymous forces, we do feel in control of our actions, masters of our own fate. We feel a sense of exhilaration, a deep sense of enjoyment that is long cherished and that becomes a landmark in memory for life should be like.

His insight grew out of his wide-ranging studies of what makes people happy. Csikszentmihalyi was surprised when people said what gave them the most joy and happiness was not leisure or passive entertainment but self-directed, challenging experiences that required total focus.

With these conditions, people would enter a timeless state of action without an inner critic. And when they returned to their normal “non-flow” existence, they felt refreshed and energized by their time “in flow,” despite being often physically or mentally depleted from the effort.

Csikszentmihalyi identified several key factors, or conditions, for producing flow:

  • Complete concentration on the task
  • Clarity of goals and reward in mind
  • Immediate feedback
  • A balance between challenge and skills
  • A feeling of control over the task
  • The experience is intrinsically rewarding

Csikszentmihalyi’s studies were relegated the backwaters of psychological research as mainstream researchers focused on the causes of and possible treatments for negative mental conditions, such as depression and anxiety.

Publication of his national bestseller, “Flow, the psychology of optimal experience[2]” in 1990; however, provided psychologists and more than a few game designers, including this one, a theoretical basis and practical guide for creating flow experiences.

Creating Flow in Health Games

Designers of digital interactive games specify all aspects of the player’s experience: what they can see, hear, and do. So it’s certainly within our skill set to create engaging situations that fulfill the necessary conditions for flow–if we know how. The following sections reveal the secrets for meeting Csikszentmihalyi’s objectives and creating flow in health games.

Flow Condition #1: Complete concentration on the task

Health games should allow the player to concentrate on performing only one or two key actions at each step of the game. Providing too many options can sidetrack the player into evaluating the different alternatives instead of focusing on one or two key actions to achieve game success.

Psychologist Timothy Galway explored the differences between the “thinking about”and “doing” brain in his book, “The Inner Game of Tennis [3]” The “thinking about” brain has its merits; it’s how we learn by comparing and contrasting evidence and connecting new information to our existing knowledge. But to achieve “peak performance,” Galway stressed, you need to put the evaluating and judgmental part of your brain in the back seat and focus straight ahead on the task.

Focused Beam of Light: Metaphor for Flow.

In the “Designing Health Games” course I created and taught at the American University Game Lab, I often compared the directed attention of flow to a searchlight that focuses all its light in a concentrated beam. Anything we can do to help players achieve this focused state will improve their gaming experience and through that, their health.

Flow Condition #2: Clarity of goals and reward in mind

The goal of a health game should be fairly simple. Here some examples of the goals in games I’ve designed:

· Find the hidden numbers (cognitive game to help kids with severe anxiety)

· Stand up and sit down to move a virtual rail car along a track (balance game for people with Parkinson’s disease)

· Grab balloons that have words you need to remember (memory game for people with MS)

· Shift your weight to smash planets with your spaceship (balance game for children with cerebral palsy)

With some health conditions, it may be necessary to address multiple aspects of the person’s physical or mental capabilities. In my experience, it’s often been better to create several mini-games instead of attempting one comprehensive game. This allows the designer to tailor each mini-game to a specific clinical need.

Rail Runner Mini-Game for People with Parkinson’s Disease

Rail Runner was one of nine mini-games we designed with Glenna Dowling and Marcia Melnick at the UCSF School of Nursing, each one targeting a different aspect of the patient’s gait and balance. The subjects in our study nearly tripled their amount of exercise over 12 weeks, which led to measurable improvements their balance and gait.

Flow Condition #3: Immediate Feedback

Players need to know when they’re doing a game task correctly (or not) so they can quickly correct mistakes. Lack of clear feedback can lead to confusion, which will break their concentration, and drop them out of flow.

In addition, you need to display the feedback where the player will see it. Players won’t notice a small update in their score if it’s displayed in a box at the top of the screen while they’re focusing on avoiding an obstacle in a driving game or trying to catch tokens as they fall. Eye-tracking studies will show you where to place the feedback; although common sense will also often work. Players will focus where you direct them to look (with animation and dynamic graphics).

We employed this tactic in a game to help children with cerebral palsy improve their balance. A key goal was helping them learn to shift their weight without bending over. The game asks players aim their spaceship to crash into targets or planets by shifting their weight on a Wii-fit board.

We tried several different ways to provide feedback when a child was leaning over so that he/she would see it and shift their weight correctly. The game was very dynamic and getting their attention was difficult.

Our solution: we displayed the feedback exactly where the player was looking. We changed the color of the spaceship they were controlling from green (good posture) to red (leaning over).

In a small test, we turned the feedback on and off between game levels and measured how many times the player leaned over during each level. Clearly this feedback strategy worked.

As you are designing your game, you need to provide clear and immediate feedback. You also need to deliver it in a way that players can easily see it and react to it while playing a challenging game.

Flow Condition #4: A balance between challenge and skills

The design task of creating game challenges of “appropriate difficulty” directly addresses this requirement. We can not only adjust the difficulty of a game level but also assess the player’s skill at the same time.

Flow Occurs When Difficulty Matches Ability

The green diagonal line in this graph shows how flow occurs when game difficulty and ability are matched. It also shows what happens when they’re not in balance. People will quickly get frustrated with a game that’s much too hard for them and will soon tire of a game that is way too easy. The green line fades away from the diagonal because players will “drop out of flow” as the imbalance between ability and difficulty increases.

Methods For Matching Ability and Difficulty

There are several ways to create game challenges that match a broad range of player abilities but the two most prominent are closed-loop design and difficulty staircase progression. A future article will explore the strengths and weaknesses of these complimentary approaches and a provocative hybrid that leverages their specific advantages.

Flow Condition #5: There is a feeling of control over the task

Within a game or game level, players tend to be more engaged when they feel they’re in control. This is part of the “designer-player contract” of game design. The designer creates a set of rules for how to play the game and if the player follows those rules, then they should win. Violate that “contract” and you’ll have an angry bunch of players on your hands. Or more likely, they’ll just quit and won’t play anything you design, ever again.

Additional support for the importance of control comes from the Self-Determination Theory (SDT) developed by Richard Ryan and Edward Deci[4]. Their research into the factors that affect people’s motivations to learn something new or change their behavior identified “autonomy”–being able to direct your actions–as one of the key components of success in effecting change. Your design should empower the player’s sense of control within the game and you need to confirm this with careful user testing.

Flow Condition #6: The experience is intrinsically rewarding

Health games typically rank high on this condition because players have chosen to play the game to improve their physical or cognitive condition and few things are as important to us as our health. This differentiates health games from the larger class of interactive games whose primary goal is entertainment. Our games have to be engaging and produce measurable benefits.

Collaborators on and Funders of My Health Game Projects

But this poses a burden on the health designer to fulfill that promise. One of the ways I’ve done this is by partnering with leading clinical researchers, often on NIH-funded projects. We would adapt and extend their proven non-gaming approaches to produce engaging games that provide measurable health benefits.

The Bigger Picture

Creating engaging flow experiences in health games is just the first crucial part of a powerful “multi-timescale” health game design strategy that includes specific tactics for the Seconds, Minutes, and Weeks timescales. Health games only work if people play them often and long enough for the small incremental benefits of each session to accumulate. The next article in the series will explore some aspects of the “designer’s toolbox” for each of these timescales: Timescale Strategies for Better Health.

This series is based on my experience designing and managing the production of four, in-depth clinically-inspired games that helped a diverse group of people: seniors with Parkinson’s disease, children with cerebral palsy, adults with multiple sclerosis, and kids with severe anxiety. I really enjoy applying my game design and team-building skills in the creation of games that can help people get better.

My efforts in creating and teaching the Designing Health Games course at the American University Game Lab (2016–2019), helped gel some ideas that I’ve shared here. I had to update the syllabus every year to keep up with this rapidly emerging field!

This article was originally published on medium.


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Robert Hone







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