The Secrets of Creating Effective Health Games — Timescale Design
How to create digital therapeutic games that motivate people on multiple timescales
Your doctor may soon prescribe a digital therapeutic to help combat the effects of ADHD, depression, diabetes, or anxiety. These software-based treatments leverage advances in neuroscience, psychology, and health game design to provide “unmedicated” approaches to these chronic conditions.
Guiding people into a flow state, as described in the first article in this series, is a good start but not nearly enough. Just as going to the gym once doesn’t get you in shape, you need to play these “training” games many times over 6–12 weeks to produce lasting benefits.
A proven multi-timescale approach targets seconds, minutes, and weeks–all at the same time–and each with its own set of tactics. Strategies for the Seconds timescale focus on guiding players into a flow state. Minutes strategies focus on making game levels engaging and memorable. And Weeks strategies motivate players to keep playing to produce results.
This article provides an overview of this proven Timescale Design approach, which will be expanded upon in a series of posts exploring the strategies for each timescale in more detail.
Seconds — Flow
The success of your DTx game crucially depends on your design of the second-by-second gaming experience. Get this wrong and the rest won’t matter because the player will quit.
Properly designed games can induce the hyper-focused “flow” state where players get deeply engaged in a game. Guiding a player into a flow state depends on three key factors: initial success, automaticity of the game UI and appropriate difficulty.
Initial Success
Any new interface poses a cognitive challenge and gaming interfaces–which include game controls, a gaming environment, and visual feedback–are much more complicated than most interfaces. Add to that the set of game rules that players must learn and it all adds up to demanding situation. Trip Hawkins, the founder of Electronic Arts, one of the world’s largest game companies, came up with a clever solution when they were designing one of the first digital basketball games.
We set up the program so that it didn’t matter where the player took the first shot. It could be at the back of the basketball court … we forced the ball to go through the basket! This positive result put the player at ease and gave them the confidence to explore the rest of the interface and the game.
Design your games so that nearly everyone successfully completes the first game challenge (and test your game with typical players to confirm this). You can then gradually ramp up the difficulty to produce the positive health benefits you’re hoping to produce.
UI Automaticity
If you’re a touch typist, your brain has learned to “offload” some of the conscious cognitive effort of typing to subconscious processing. You type “through” the keyboard not “with” it. The keyboard has become an extension of your mind.
The brain invokes automaticity of a trained action to free up conscious effort so it can be applied to more important stuff like which words to type. When cognitive scientists point out that we don’t really multitask, they’re talking about conscious mental effort, which can only be directed at one task at a time (and switched back and forth).
But with automaticity, your brain is actually multitasking much of the time. How does this relates to game design? The game user interface should be easy to learn so that players can “offload” some of the cognitive effort of operating the interface to automatic subconscious processing.
I recently designed a suite of adaptive interactive tutorials for the Neuroscape Lab at UCSF that allowed seniors in assisted living centers to first focus on learning the game UI. The tutorial provided helpful feedback when the player made a mistake and repeated a simple game challenge until the player demonstrated they understood the game controls. Only then could the players start playing the adaptive cognitive games intended to improve their working memory and task-switching abilities.
Appropriate Difficulty
Players like to be challenged and will quickly lose interest if the game is so hard that it’s frustrating or so easy that it’s boring.
Winning a computer game should be like winning a tennis match 7–6, 6–7, 7–6. Trip Hawkins, Founder of Electronic Arts
Your success in creating “appropriately difficult” game challenges will make the difference between an effective gaming therapy and an app that’s only played a couple of times before it’s ignored, then forgotten.
The following short summary covers the key elements of the two most prominent methods for matching game difficulty to player abilities. I’ll explore this crucial topic in greater detail in the next article, “Secrets of Generating the Goldilocks Condition–not too hard, not too easy.”
Closed-Loop — In a Closed-Loop design, the game continually assesses the player’s ability and adjusts the game difficulty to match it. If the player is doing really well, the game gets harder, and vice-versa. In the game design world, this is called rubberbanding or dynamic difficulty adjustment. The game “rubberband” provides the dynamic tension that produces flow and adjusts depending on how hard the player’s actions are stretching it.
This efficient approach produces the most benefit per unit time–not unlike a treadmill that continually adjusts its speed depending on your heart rate. The downside is that because the players can’t determine the difficulty, they can get frustrated with the loss of control.
The Self-Determination Theory by Ryan and Deci emphasizes the importance of player autonomy–the ability to affect and control your situation. Reducing this autonomy can lead to burn out and/or people stopping the gaming therapy [1].
Difficulty Progression — Another approach provides a set of progressively more difficult game levels that players can choose (a “staircase” of game levels). Sometimes a player/patient may not be at their best, physically or cognitively, and would prefer an easier game level. On other days, players may be feeling better and up for a more challenging experience.
The downside of this approach is that because the player selects the difficulty–instead of the game algorithm– the players’ efforts aren’t as maximized for health benefits as in the Closed-Loop approach.
Minutes — Quests
Presuming you’ve followed the tactics of the Seconds timescale and designed an engaging game that guides players into a flow state, now you need to think about how to keep them actively engaged for a longer period of time to generate the beneficial effects you’re hoping to produce.
The successful AAA consumer video game companies have learned through extensive user research that most people prefer a focused, energetic effort that lasts only 5–10 minutes. With this as a general guide, there are a few key features to include in your game levels to optimize player engagement at this timescale.
Variable Difficulty
Even though five minutes seems like a short period of time, it’s still a good idea to adjust the difficulty of a game over the course of the level if that’s possible with your design.
The game should start relatively easily (compared to the rest of the level) to help the player get up to speed and then gradually get harder. A mid-level “lull” gives the player a rest before the difficulty ramps up to the end.
I designed a cognitive game with researchers at the National Institute of Mental Health (NIMH) that employed this technique to provide an engaging puzzle challenge for children with severe anxiety.
The game mimicked a successful therapy developed by Dr. Daniel Pine of the NIMH that helped children with anxiety reduce their symptoms by “detaching” from their maladaptive focus on negative images. My design involved illustrated classroom scenes with some of the children looking angry.
The players were challenged to find numbers hidden in the scene … that we deliberately placed far away from the “triggering” faces. The only way the kids could find the numbers was to look away from the threatening faces! The game the same as Dr. Pine’s therapy in a more engaging context.
Within each puzzle, we created a varied set of hidden numbers: one was easy to find, seven to eight were medium difficulty, and one or two were hard to find. Through data analysis, we could track the order when each number was found and it matched this difficulty sequence. The players found the easy ones first, then spied the moderately hidden ones, and then tried to find the most hidden numbers.
Memorable Endings
The importance of providing memorable feedback at the end of a game level and end of a training session cannot be overstated. As Nobel prize winner Daniel Kahneman has brilliantly demonstrated, we remember the end of experiences much more so than the beginning or the middle [2]. Your design should leverage this unusual aspect of human memory to provide memorable conclusions to game levels.
The cognitive puzzle game was originally planned as a prototype that we’d use to collect user data and then build a more robust and polished version. Dr. Pine and his colleague Dr. Yair Bar-Haim were so excited about the prospects for the gaming therapy, that they asked us to quickly build the reporting screens so they could start their study with the prototype version. We would have designed and produced more “memorable” screens with the additional time and funds available in a full project.
Highlight positive outcomes with playful animations and provide reassuring feedback for negative outcomes. Use synchronized sound effects to enhance the visual feedback. These efforts will encourage players to try the next level or repeat the same one for another try.
The end of a game session should include a reassuring summary of the player’s game level accomplishments and comparisons to previous sessions. Completing a gaming therapy session is a victory in itself. If a player’s current session isn’t as successful as a previous one, with lower scores for example, provide an encouraging explanation to compensate for any negative feelings they may have (e.g. “that’s ok, people’s scores don’t always get better”).
By structuring your end of game session “wrap ups” this way, players will be more likely to take on their next scheduled gaming session because you’ve helped leave them with a positive memory of the last one.
Weeks — Campaigns
No one expects to get in physical shape without numerous workout sessions. And developing a new cognitive skill like learning a new language requires significant amounts of effort. Physical and cognitive digital therapeutic games slowly and steadily improve people’s health–but only if they put in the time and effort.
Here are several techniques for motivating players to stick with their training sessions long enough to see results. I’ll cover some other motivational strategies such as remote team vs. team competitions and social reinforcement in a future post.
Difficulty Staircase Progression
This approach not only lets people select the appropriately difficult game level for their current ability but it also lets them advance to harder levels as they improve.
On one of my projects, physical games for people with Parkinson’s disease, many patients surprised our clinical partners at UCSF by reaching the top of the staircase, tripling their amount of exercise, and improving their balance.
The height of each “step” in the staircase should be tall enough so that the player has a roughly 50–50 chance at winning the level on their first try. Those who don’t win the first time will be close enough to try again.
Training-Competition Hybrid Approach
This approach combines the optimizing features of a Closed-Loop approach during strenuous “training sessions” with a staircase of preset difficulty “competition” levels that let players select the difficulty of their challenge.
The steps of the difficulty staircase in the hybrid approach should be taller with a greater increase in difficulty than with the staircase-only design. This motivates players to work hard in the training sessions to meet the more difficult challenges of the next competition level.
Virtual Partners
Have you ever gone running with a friend who is slightly faster than you? Chances are, you worked extra hard to keep up with them. This phenomenon, called the Köhler Effect, can be added to either the difficulty staircase or hybrid approaches through the use of virtual partners.
Nearly a decade of research by Deborah Feltz and others at Michigan State University has shown that the Köhler Effect works for virtual 3D “training partners” and not just fellow humans [3].
Wrap-Up
This is the second article in the Secrets of Designing Effective Health Game series. If you haven’t checked out the introductory article, you can click the link below. I plan to release one a week for the next few weeks so keep an eye out.
1) How Health Games Create Flow to Help People Battle Chronic Diseases
2) Secrets of Timescale Strategies for Health Games (this one)
3) Secrets of Generating the “Goldilocks Condition” in Health Games
4) Secrets of Creating “Clinically-Inspired” Health Games
5) Secrets of Engineering Efficacious And Effective Health Games
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. I had to update the syllabus every year to keep up with this rapidly emerging field!
Any and all comments welcome!
[1] Deci E.L., Ryan R. M., Self-Determination Theory. Canadian Psychology, Canadian Psychological Association 2008, Vol. 49, №3, 182–185
[2] Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.
[3] Moss T., Feltz D., et al, Intergroup Competition in Exergames: Further Tests of the Kõhler Effect, GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications, Volume 7, Number 4, 2018
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