© Lennart Nacke, 2016. This is the author’s version of the work. It is posted here for your personal use. Not for redistribution. The definitive version was published in CHI PLAY Companion '16 Proceedings of the 2016 Annual Symposium on Computer-Human Interaction in Play Companion Extended Abstracts, https://doi.org/10.1145/2968120.2971804We present Above Water - a digital/physical hybrid game to inform people about the available strategies to cope with two types of Anxiety Disorders - Generalized Anxiety Disorder and Panic Disorder. The game teaches players about existing treatments. This hybrid game is designed to inspire players to share their experiences and develop their own personal narrative. The document also outlines an assessment strategy to study the game and determine its effectiveness as a game for health. The game is designed to educate non-institutionalized individuals with clinical anxiety and panic disorder. Potential players may be diagnosed, seeking intervention information, or a supportive friend.Peer-reviewe

Fortes Tondello, Gustavo

Ganaba, Marim

Lee, Alvin

Nacke, Lennart

Stocco, Melissa

Watson, Diane K.

Wehbe, Rina Renee

Rina R. Wehbe

Diane K. Watson

Gustavo F. Tondello

Marim Ganaba

Melissa Stocco

Alvin Lee

Lennart E. Nacke

Crossref

ABOVE WATER

University of Waterloo's Institutional Repository

ABOVE WATER: An Educational Gamefor AnxietyRina R. WehbeHCI Games Group, GamesInstitute and David R. CheritonSchool of Computer Science,University of WaterlooWaterloo, ON, Canadarina.wehbe@uwaterloo.caDiane K. WatsonTouchLab, Games Institute andDavid R. Cheriton School ofComputer Science, University ofWaterloo, Waterloo, ON, Canadadiane.watson@uwaterloo.caGustavo F. TondelloHCI Games Group, GamesInstitute and David R. CheritonSchool of Computer Science,University of WaterlooWaterloo, ON, Canadagustavo@tondello.comMarim GanabaHCI Games Group, GamesInstitute, University of WaterlooWaterloo, ON, CanadaMelissa StoccoHCI Games Group, GamesInstitute, University of WaterlooWaterloo, ON, CanadaAlvin LeeHCI Games Group, GamesInstitute, University of WaterlooWaterloo, ON, CanadaLennart E. NackeHCI Games Group, GamesInstitute and David R. CheritonSchool of Computer Science,University of WaterlooWaterloo, ON, Canadalennart.nacke@acm.orgPermission to make digital or hard copies of part or all of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for third-party components of this work must be honored. For all other uses, contact the Owner/Author.Copyright is held by the owner/author(s).CHI PLAY’16 Extended Abstracts, October 16-19, 2016, Austin, TX, USA.© Lennart Nacke, 2016. This is the author’s version of the work. It is posted here for your personal use. Not for redistribution. The definitive version was published in CHI PLAY Companion '16 Proceedings of the 2016 Annual Symposium on Computer-Human Interaction in Play Companion Extended Abstracts,http://dx.doi.org/10.1145/2968120.2971804AbstractWe present Above Water - a digital/physical hybrid gameto inform people about the available strategies to cope withtwo types of Anxiety Disorders - Generalized Anxiety Dis-order and Panic Disorder. The game teaches players aboutexisting treatments. This hybrid game is designed to inspireplayers to share their experiences and develop their ownpersonal narrative. The document also outlines an assess-ment strategy to study the game and determine its effec-tiveness as a game for health. The game is designed toeducate non-institutionalized individuals with clinical anxi-ety and panic disorder. Potential players may be diagnosed,seeking intervention information, or a supportive friend.Author KeywordsGame for Health; Psychology; Mental Health.ACM Classification KeywordsJ.3 [Computer Applications]: Health; K.8 [Personal Comput-ing]: Games.IntroductionThe game Above Water is designed to educate playersabout generalized anxiety disorders and panic disorders.Potential players could have a clinical diagnoses, be seek-ing information about a suspected problem, or playing asupportive role in another individual’s journey to health.79The game is not designed to be a treatment itself, but in-stead provides information that may empower individuals toseek treatment by creating awareness about different op-tions, and encourage conversation between players. Thegame acknowledges that the effectiveness of treatments ispersonal to each individual and focuses on treatments aspieces of a treatment plan that contribute to better overallhealth and wellness.Understanding Mental HealthFigure 1: Life Goal cardsrepresent some of the player’spersonal goals, reflected in theirin-game goals.Anxiety Disorders, according to the Diagnostic and Sta-tistical Manual of Mental Disorders IV (DSM-IV), refer to afew different disorders including Generalized Anxiety Dis-order, Panic Disorder, Phobias, Social and Separation Anx-iety Disorders. Disorders are pervasive and disrupt dailyfunctioning; in other words, they are not the typical worryor anxiety faced by a healthy individual. Anxiety caused byAnxiety Disorders is often disproportionate to the cause,extends over a long period of time, and can disrupt dailyfunctioning [1, 7].Although all types of anxiety disorders are serious and wor-thy of treatment, our game will specifically focus on Gener-alized Anxiety Disorder and Panic Disorders.Generalized Anxiety Disorder (GAD) causes the afflictedperson to experience ongoing daily anxiety, which can bedisruptive to their daily life. Anxieties revolves around ev-eryday life experiences and responsibilities of the individual(e.g., appointments, homework, or domestic duties). Phys-ical symptoms (e.g. muscle fatigue, sleeping irregularities,etc.) can also accompany the mental symptoms of feelinganxious, restlessness, or feeling on-edge [7].Panic Disorders are characterized by the onset of panicattacks that can be triggered or appear randomly. Panic at-tacks are a combination of physical and mental symptomsthat overwhelm the person. Although experiences with thedisorder vary, the attacks may be accompanied by any of:increased, irregular heart rate, sweating, fatigue, hopeless-ness, loss of control, and overwhelming fear [7].Treatments OverviewThe following types of treatments or strategies for dealingwith anxiety will be presented to players on the treatmentcards. We offer a brief conceptualization of each treatmentor strategy and pointers for additional literature.The game raises awareness of different available treat-ments, including Cognitive Behavioural Therapy (CBT) [2],Medications [7], Somatic Experiencing [5], and CognitiveReappraising [3]. Additionally, everyday life changes suchas the importance of exercise [4], avoiding caffeine [7], aswell as relaxation techniques [6] are emphasized. Activitiesin the digital component of the game act as an introduc-tion to self-help methods. Additionally, links are provided toonline information from trusted resources on the accompa-nying mobile application.Informing the players about possible treatments is only halfthe battle; access to therapies can often be the next bigchallenge. The digital part of the game is also designedto address this challenge by linking to online resources,e.g. the Centre for Addiction and Mental Health’s (CAMH)Thought Spot application1, which allow users to researchplaces to obtain treatment from a trusted organizations.GameplayAbove Water is a game that players play with physical cardsand digitally with personal devices (such as tablets or smart-phones). The game is designed to be co-located, collabora-tive, and synchronous with other players.1http://mythoughtspot.ca/80MaterialsThe game is played using the Above Water card deck andplayers’ personal devices. In the deck there are four cardtypes: life goals, anxiety, treatment, and share cards. Thereare 61 cards in the deck: 24 Life Goal cards, 20 Anxietycards, 12 Treatment cards, and 5 Share cards.2 The gameis designed to be played with four players.Figure 2: Anxiety cards representthe challenge imposed by anxietydisorders and can be countered byTreatment cards.ObjectivesThe objective of the game is for players to achieve all oftheir life goals while managing anxiety. In this game, goalstake the form of six collectible cards (e.g. Career, Educa-tion, Health, Self Improvement, Financial Stability, and Re-lationship goals). Before starting the game, each playermust select four Life Goals on their smart phone or tablet,which will make their objective for that particular play ses-sion. The objective cannot be changed once the game hasstarted.End of gameThe game ends when the winning condition is met. A playerwins when they have achieved their goals (i.e., they havecollected their chosen Life Goal cards that represent theirobjective) and their anxiety counter is at zero (i.e., the playerhas no anxiety cards in hand).Game MechanicsOn each players’ turn they will draw one card from the deck,which they will then place on the table face up, play or dis-card. Anxiety cards that the player has in hand can also bediscarded by using treatment cards.Life Goal CardsLife goal cards were designed to encourage players tothink or talk about their personal life goals. These cards2The online browser game available is at: http://play.hcigames.com/abovewater/(Figure 1) represent some of the player’s personal goals.Before the game starts, each player chooses three goalsto collect during gameplay. The player will announce tothe team which goal cards they are pursuing and tell theteam what they are trying to accomplish (e.g., "I will col-lect an Education card to represent my goal to do well inmy Games for Health class, and one social card that repre-sents my goal to make friends with the other students"). Lifegoal categories are broad to cover most areas of life goals,but still give guidance to help formulate their goals. Sincegoals in life are often diverse and multifaceted, players mustchoose four different life goals from the eight different op-tions provided. This mechanic in the game facilitates opencommunication and asks players to develop their own per-sonal narrative.Anxiety CardsWhile the players are collecting cards they may unfortu-nately pick up an Anxiety card (Figure 2). The player’s goalis to discard all anxiety cards, but they cannot be discardedwithout a treatment strategy. If the player’s anxiety countergoes up it will inhibit their gameplay strategy. For each turnthe player has a full anxiety card counter (5), they will havea panic attack, where they must discard one card (otherthan an anxiety card) and lose a turn. The player’s anxi-ety card count will be reduced to four cards following themissed turn, allowing them to play again. This mechanicwas designed to teach players about the dangers of notdealing with their anxiety and allowing it to progress. It alsois a metaphor for life with an anxiety disorder because it ispervasive and disrupts everyday functioning.Debunking Mental Health MythsThis game is meant to inform players about common men-tal health myths, as well as helpful facts. The game is trig-gered by picking up an Anxiety card with an app icon on81it. When players proceed to the app, they will have to de-termine whether the presented ’fact’ is true within the timelimit.Treatment CardsFigure 3: Treatment cards counterAnxiety cards, some by completingan activity on the player’s personaldevice.Various treatments and strategies are available for individ-uals with anxiety disorders. Treatments on these cards arebased on the literature for treatment of anxiety and panicattacks. In reality, treatments do not all have the same ef-fectiveness level for everyone. The goal is not to prioritizedifferent treatments, but to raise awareness of different op-tions.Within the game, we have based the effectiveness of thegame on the degree of assistance needed from a profes-sional for each treatment. To symbolize this, each Treat-ment card (Figure 3) will have an associated number thatdefines how many Anxiety cards it is capable of removing(from 1 to 4). For example, an exercise session may be ca-pable of treating only one Anxiety card, while a session oftherapy requiring a therapist may be able to treat two orthree anxiety cards. Treatment cards can be used at anymoment during a player’s turn. When a Treatment card isused, it is discarded by the player together with one or moreAnxiety cards.The maximum amount of Anxiety cards that can be dis-carded is equivalent to the potential of the Treatment card.The player can use more than one different type of Treat-ment cards in the same turn to discard more Anxiety cards.For example, the player can use an Exercise Treatmentcard and a Therapy Treatment card in the same turn. How-ever, only one card of the each Treatment type can be usedper turn, thus the player cannot use two cards of the sametype of therapy on the same turn.Some treatment cards will activate an interactive experi-ence using the application. The interactive experiences al-low the game to have educational moments that all playerscan participate in.Deep Breathing ApplicationThe deep breathing game walks players through a breath-ing exercise. It demonstrates how heart rate can be con-trolled by fast and slow breathing to promote deep breath-ing relaxation techniques.Yoga and Stretching ApplicationThe mobile app is used to show a yoga or guided me dona-tion pose (Figure 4). Players take a moment to stand andstretch while trying the exercise. The phone assesses theplayer’s balance by using accelerometer data. This allowsplayers to assess how successful they were at the activityand enables some in-game competition between players.Share CardsIf a player picks up a Share card (Figure 5) they will be re-ferred to the app. The app will randomly pick a questionfor the players to answer. There are three categories: Tip,Share, and Create. Players maybe asked to ’share’ a strat-egy that helps them deal with anxiety, give advice or ’tips’on how they personally deal with anxiety, or ’create’ a ques-tion to be answered by the group. Create Share cards willalso give players the opportunity to discuss a strategy oftheir own. This encourages conversation and personal-ization of the game. These cards are meant to facilitatedialogue between players and help them relate their experi-ences with the information being presented by the game.The application anonymizes the answers, and hides playeridentity. More information is conveyed about privacy andsensitivity of the game in an upcoming section.82Discarded cards and the PilePlayers will draw cards from the top of the deck and discardthem into a separate pile face up. Once all of the cards arediscarded, they should be reshuffled and made into a newpile. The game can then resume and progress normally. Inaddition, the Group Therapy treatment card will ask playersto reshuffle the deck immediately after being drawn.Privacy and SensitivityFigure 4: The companion mobileapplication is used to guide playersthrough a yoga pose exercise.For privacy and sensitivity, the application has been de-signed to assist players in creating a more anonymous,open environment for play. The app randomizes answersand employs partial presentation of group responses toprotect player identity. Each player is able to answer indi-vidually on their mobile device; unlike other games, playersdo not hand-write answers and cannot be identified by theirwriting. Furthermore, question are designed to be indirectand non-threatening. Additionally, players can also role-playas a character of their choosing. This is a helpful option be-cause the player can discuss the feelings and challenges ofthe disorder without disclosing personal information, thussupporting privacy.ArtThe game is designed to be a card game with an approach-able water-colour art style. The design is simplistic andmeant to avoid provoking anxiety. Colours like blue andgreen are used heavily. Additionally, life goal cards aremade to look like rewards to encourage positive thoughtsabout players’ end goals. Consequently, it encourages play-ers to separate their goals from their anxieties.The game’s name, Above Water, is meant to inspire themetaphor of "keeping your head above water". This reflectsthe game’s goal to teach coping methods, educate playersabout the treatments for the disorder, provide motivation,and encourage to pursue academic and career goals. Thisis especially important because many sufferers of anxietydo not seek help or understand their disorder as curablewith the adequate treatments [7].TechnologyAbove Water is a physical/digital hybrid that uses physi-cal cards and personal digital devices to enable interac-tive experiences. The digital implementation does not re-quire players to download an app, instead it uses a simpleHTML5 enabled website. This allows the game to accessaccelerometer data from the personal devices, and be com-patible with most modern devices without needing to bedeveloped for multiple platforms. To start the game, oneplayer must create a game instance that provides a codefor the other players, allowing the game to be synchronizedacross all devices. When an interactive experience is trig-gered, the game master (the player who created the gameinstance) selects the interactive experience, and all playerswill participate.DiscussionCollaboration and Narrative GameplayThe game is designed to be collaborative and foster com-munication between players. Discussing about mentalhealth is important to everyone, even those taking a sup-portive role.The digital activities are designed to get players to inter-act and achieve goals together. The application allows foranonymization of comments allowing for a more open envi-ronment for players who may not want to disclose personalinformation.Share cards are part of the collaborative nature of the gameand compliment the narrative game mechanics. Further-83more, Share cards allow for customization and personaliza-tion through by allowing players the opportunity to createquestions when prompted by the application.Figure 5: Share cards allowplayers to progress their ownnarratives or share personalexperiences.Built-in LearningThe mechanics of the game are designed to teach peoplein a natural way by allowing the association of information.Cards for managing in-game anxiety provide informationfor techniques that may be used to help the player managetheir own anxiety in real life, ultimately tying the excitementof an in-game treatment card with information about a pos-sible treatment strategy. By accessing the application, play-ers can find additional resources and information.AcknowledgmentsThe authors would like to thank Prof. Chrysanne DiMarco,Raymond A. Mar, Rita Orji, Elisa Mekler, and our reviewersfor their feedback. We would also like to thank Andrew ofthe Center Addiction Mental Health (CAMH), and Miriamfrom Bloom and Kid’s Help Phone for their feedback. RinaWehbe would like to thank the Cheriton School of ComputerScience, University of Waterloo, and NSERC for fundingher research. Gustavo Tondello would like to thank the Uni-versity of Waterloo and the CNPq, Brazil for funding hisresearch. This research has received funding from NSERC(RGPIN-418622-2012) and SSHRC (895-2011-1014, IM-MERSe). A special thank you to the Games Institute forsupporting this research.REFERENCES1. Gavin Andrews, Megan J. Hobbs, Thomas D.Borkovec, Katja Beesdo, Michelle G. Craske,Richard G. Heimberg, Ronald M. Rapee, Ayelet MeronRuscio, and Melinda A. Stanley. 2010. Generalizedworry disorder: a review of DSM-IV generalized anxietydisorder and options for DSM-V. Depression andAnxiety 27, 2 (2010), 134–147. DOI:http://dx.doi.org/10.1002/da.206582. TD Borkovec and E Costello. 1993. Efficacy of appliedrelaxation and cognitive-behavioral therapy in thetreatment of generalized anxiety disorder. Journal ofConsulting and Clinical Psychology 61, 4 (August1993), 611–619. DOI:http://dx.doi.org/10.1037//0022-006x.61.4.6113. Alison Wood Brooks. 2014. Get excited: reappraisingpre-performance anxiety as excitement. Journal ofExperimental Psychology. General 143, 3 (June 2014),1144–1158. DOI:http://dx.doi.org/10.1037/a00353254. JD Brown and JM Siegel. 1988. Exercise as a buffer oflife stress: a prospective study of adolescent health.Health Psychology : Official Journal of the Division ofHealth Psychology, American PsychologicalAssociation 7, 4 (1988), 341–353. DOI:http://dx.doi.org/10.1037//0278-6133.7.4.3415. Peter A Levine. 1997. Waking the tiger: Healingtrauma: The innate capacity to transform overwhelmingexperiences. North Atlantic Books.6. Lars-Göran Öst and Bengt E Westling. 1995. Appliedrelaxation vs cognitive behavior therapy in thetreatment of panic disorder. Behaviour Research andTherapy 33, 2 (1995), 145–158.7. R. Parekh. 2015. What are Anxiety Disorders?American Psychiatric Association. (2015).http://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders Accessed: 2015-12-15.84

ABOVE WATER: An Educational Game for Anxiety

ABOVE WATER: An Educational Game for Anxiety

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