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Creating Flow in Health Games

Part 1 of the Secrets of Health Game Design series

We’ve all probably experienced the focused flow state at one time or another in our lives. It could have been while running, skateboarding, surfing, or any one of many athletic pursuits.

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

Psychological researcher Mihaly Csikszentmihalyi (pronounced: me-high, cheek-sent-me-high) coined the term “flow” to describe a hyper-focused state where our sense of time fades away and tasks seem effortless. 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:

And when people achieve a flow state, they experience:

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 (“real researchers don’t study happiness”).

An emerging stream of advanced software-based health treatments offers new hope for people struggling with many chronic diseases and conditions such as ADHD, depression, diabetes, anxiety, and many others. Companies such as Pear Therapeutics, Akili Interactive, and several others have received FDA approval for their products or are awaiting possible/likely approval. Your doctor may prescribe a health game to help you or your child overcome a medical challenge … or will soon.

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 each of Csikszentmihalyi’s objectives and creating flow in health games.

Health games should enable 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.

In the “Designing Health Games” course I created and taught at the American University Game Lab, I 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.

This requirement really has two components, clear goals and immediate feedback, which involve different design approaches.

Clear goals — First off, the goal of a health game should be fairly simple. Here some examples of the goals in games I’ve designed:

If you want to create game challenges that demand more than one goal to address several aspects of a person’s physical or cognitive condition, then you should create several games, or “mini-games,” with each one targeting only one, or possibly two, aspect(s) of the player’s condition (but preferably only one).

The stand up/sit down example from above 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. Over the twelve week therapy, the people in the study increased their amount of exercise by an average of 180%. They also consistently took on harder challenges as they got stronger, both of which led to measurable improvements in their balance and gait. I’ll provide more information about this project in coming articles (we learned a lot).

Back to keeping things simple. Your game introduction should clearly describe the goal of each game level and the actions to achieve success. The interactive tutorial should let the player test out the game interface to get that learning done as soon as possible. If a new game level involves a new action or actions, then provide a short interactive tutorial to let the player learn and practice the new action.

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 often also work. Players will tend to 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 asked players to aim their spaceship to crash into targets or planets by shifting their weight on a Wii-fit board.

We also tracked their posture with a Wii on their chests to see if/when they were improperly leaning over instead of standing straight and shifting their hips. Children with CP often make this undesired “compensatory motion” when they struggle to move their hips correctly.

We needed to display feedback on posture so a child would notice 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. The results clearly showed that this feedback approach worked.

So immediate feedback is crucial, as is displaying it where they’re looking!

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

The green diagonal line in this diagram shows how flow occurs when game difficulty and ability are matched. It also indicates 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.

There are several ways to create game challenges that match player abilities but the two most prominent are closed-loop design and difficulty staircase progression. I’ll explore these in more detail in the article on the “Secrets of Generating the Goldilocks Game Condition.

Within a game, players need to feel that they’re in control. This is part of the “designer-player contract” of game design. The designer creates a set of rules for the game and if players follow those rules, then they should win. Violate that “contract” and you’ll have an angry bunch of players. They’ll probably quit and won’t play anything you design, ever again.

Your design should empower the player’s sense of control within the game and you need to confirm this with careful user testing. People are very “unselfconscious” when using screen-based media. Watch people as they use your game–if they’re frustrated with a lack of control or they seem lost–trust me, you’ll see it on their faces.

You’ll feel like a comedian who’s just told a joke to a live audience… and no one laughs (“designer as performer”). You need to get this painful feedback early in the process so you’ll have time to fix the problems.

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.

But this poses a burden on the health game 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 therapies to produce engaging games that provide measurable health benefits. I’ll expand on this project design strategy in the upcoming article: Secrets of Creating Clinically-Inspired Health Games.

Creating engaging flow experiences in your 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. The next article in the series will explore the “designer toolbox” for each of these timescales: Secrets of Timescale Strategies for Health Game Design.

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 experience 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. The field of digital therapeutics has been changing so rapidly that I had to update the syllabus every year to keep up with new innovations.

Here is the list of the rest of the articles in the Secrets of Creating Effective Health Games series:

Any and all comments welcome!

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