AlterConf Washington DC 2016 – Social and Design Factors in Video Games for Therapy and …


(upbeat music) – So, this is kind of a academic
title, sorry about that. For what’s really about
identity in video games and how video games
interface with who we are, what our identities are and in particular, in this space of designing video games that are explicitly created to serve as therapeutic interventions
for people who have a variety of conditions that require what would be conventionally delivered through conventionally delivered therapy. So before I get in, I want to tell a little
bit of a personal story about how I kind of came into this field. A number of years ago,
when I was in college. I was studying to be an
Engineer and a Mathematician and I got very sick, I had a
very serious Endocrine disorder that I was diagnosed with. And in the few months
following this diagnosis, I was kicked out of school, I was kicked out of my apartment, I lost all of my social group because it was entirely constructed
around being in University. I lost all of my independence, I had to move back in with my parents. And I lost all of my well being, the disease was, affected my personality, affected my mental state, it
affected my physical state. It was very difficult that it took somebody that I was and in a few months took all of that away. And over the next year and a half I started healing, but it
wasn’t really going very well. Medicine didn’t work, I eventually had to do
Radiation Treatment. Nothing really serious, but I wasn’t really getting back to the place where I wanted to be. Until I got into a video game. And this video game wasn’t
designed for therapy, wasn’t designed to like, heal
people with Thyroid disorders. It was just a video game that gave me a universe that I could be good at something. It gave me a universe that
I could connect to people and it gave me an universe
where I had choice again. And as time went on, I became better and
better at this video game. And the better I got at the video game, the more I healed. And the more I healed, the
better I got at this video game. And it had this very
positive feedback cycle to my mental and physical well being. But at the same time, there was something else
that the game was doing. And that is, right before I got sick, I had a very strong identity. I was a student, I was a
scholar, I was a researcher. I was very proud of who I was, I was very proud of what I was doing and I was beginning to
understand that I was bisexual. And I was beginning to embrace
that part of my identity. Then when I got sick, all of
that went away, it was gone. So when, I started playing this game and getting into it, as the dominating factor in my life, which was my illness,
became less and less, I tried to resurrect that identity. But the culture that was
embedded within the game prevented me from doing that. I couldn’t get back to school
because I wasn’t cleared yet, I didn’t have the money to go back yet. So I couldn’t be a student,
I was just a gamer. I tried coming out, again. And I couldn’t do that because being queer, in a
hostile gaming community, isn’t really the easiest thing to do. And gender, was like,
not even going there. So the game suppressed my identity throughout the course of it. And it wasn’t until later, when
I finally get to the point, where I quit the game, I had a job, I had relationships, it was good. I quit the game and then I was able to work on becoming who I was. And that took me about 10 years. So, I went from, on this trajectory, having that trajectory
impeded by a medical condition and then impeded by a cultural condition, that took me 10 years to recover from. And basically what the result was is that this game, participating
in it, gave me 2 choices. I could either be good
or I could be myself. It was clear when I first
started that I needed to be good. Being good was what was healing me. And so I gave up on being myself. But when I quit and started
developing games professionally, I thought about what would happen if I didn’t have to make that choice. What if we could design games
where identity was a key part of what the game was about. And we didn’t force
people to choose between being good at a video game and healing and being the person that they want to be. And so when I started to design
video game therapy systems, I didn’t really know,
couldn’t really grasp what it was about the game that
was suppressing my identity. I was looking at scientific things like what’s up with therapy? If you talk to any therapist, whether it’s a Mental Health therapist or Occupational therapist. They’ll always say that adherence to whatever is being prescribed is one of the biggest barriers to success. And video games, like
achievement-farming is super real. Right, like it’s not hard to adhere to logging into WoW everyday
so you can do your daily’s. That’s a thing that, it’s a behavior that the game has designed that people are very
good at keeping up with. Motivation in therapy is really difficult. It’s really difficult to go and get up and do the exercises that hurt you or that take time out of your day. But video games, they pull you in. You want to play them. Therapist time, it’s
really hard to come by, it’s really expensive. There are lots and lots of therapies for different conditions,
that they have shown that if you can get a
person into an office 3 times a week, that therapy
is all that is needed to recover from their condition. But, that’s a really hard thing to sell. You can’t, not everyone can afford that. Not everyone can afford
that in their schedule, not everyone can afford that
with their, financially. Insurance usually only covers a finite number of sessions per year. But with video games, now
we have all this technology. We have Kinects, we have Wiimotes, we have Leap Motions. We have Smart phones with accelerometers. So we have all this technology
that allows video games to do what a therapist could do. In a sense of it can manage
what the user is doing and it can encourage the
user to do it properly. So there’s this very attractive idea that video games and
therapy can be combined. And a lot of people have tried this. There’s a lot of products out there that claim to be workable therapy video games. And most of these products
make a few assumptions. The first being that therapy is boring. This is a video game that we designed for vision therapy for kids. On the picture here. They assume that technology
makes therapy better. There’s companies out there that build high resolution camera
systems, so that you can track what your limb is doing if
you’re doing physical therapy. There’s digital journals, if
you’re trying to quit smoking, that help you log your cigarette usage. So it’s the assumption that
technology will help us heal. We also assume that
technology makes games better. Games now are way more involved than they were 10 years ago or Fifteen years ago. We have much more technology,
we are always on Internet. We have Smart phones
that are super computers that sit in our pockets. And the other assumption
is that games are fun. We like playing games, we
have fun when we play a game. It’s a social experience,
it’s a stimulating experience and it’s something that we, that is an activity of pure enjoyment. So we look at designing a therapy and we say, okay so, let’s build a Therapy video game. What is it that we’re
going to put into the game? So one of the things that some
therapists will look at are, Activities of Daily Living, particularly in Occupational Therapy following an injury or an
acquired medical event. You might look at, the first thing you want to do is make sure that the
patient can get back to taking care of themselves. So some things are eating,
dressing, going to the bathroom. These are very basic needs
that we need to perform in order to be able to care for ourselves and retain our independence. The problem with this
is that these activities are kind of like uncanny valley. You really can’t virtualize
going to the bathroom. (audience laughs) You can but, it’s a hard sell. (audience laughs) So there is another category called Instrumental Activities of Daily Living or Instrumental ADLs. This is things like shopping,
cooking, doing housework. Taking care of your finances. Organizing your clothing, doing laundry. That sort of thing. Sort of the next level of self care. Trying to restore that
functionality to a person that has acquired a disability for example, is a primary goal of therapy. The problem with this is, these are things that
are easy to virtualize. This is the image we have here is from a video game that we built called VOTA, it’s a Virtual
Occupational Therapy Assistant. And so, in the first prototype
we had a cooking activity and we had an activity for
putting away groceries. So that works, that’s easy to virtualize. But is is really a game? Is this a game that we
can play in real life? What would we do to make it more fun? And it turns out, there
are some things you can do. But a lot of these things
are kind of boring. Like, you can only make
putting away your laundry so interesting for so long. (audience laughs) And the other issue is
that these activities for some people are also very gendered. Particularly VOTA is designed to help people following a
stroke, an acquired brain injury. And a lot of the users
of that software are Sixty, Seventy, Eighty years old. And, culturally, they
come from a place where certain people, things like shopping and putting away groceries,
that was not their work. That was the other genders’ work. And so they’re asked to
be doing this activity and it’s actually not really helping them. Their feeling very uncomfortable because they don’t understand how to do it. It’s not a thing that
they’ve ever done before and they’re feeling like
this other genders’ activity is being pressed onto them. So that’s not the best thing to do. So, there’s a lot of resistance to that. And so we think, I went
and looked back and said why is it that video games pull you in? What is it that’s about video
games that is interesting. And it turns out that games aren’t fun. They’re not, they can be, but
they’re not by themselves. Games are infuriating,
they’re frustrating. They can be inspiring,
they can be connected. They can be intersectional,
they can be captivating. But they’re not fun by themselves. I mean, I’ve been there throwing
the mouse across the room, because the raid wipe. Or you know, you think that
you’ve got your puzzle solved and you screw it up and
so you put your phone away and you go to sleep finally,
at 2 in the morning. Not that I’ve been there. (audience laughs) And so a few years ago,
it had been a few years into me designing games and
building them professionally that I came across this psychological model by a gentleman by the name of Scott Rigby who studies video games
and why people play them. And this is just one
model of why video games are fun and interesting. But his theory, is that, there are 3 basic psychological needs. The need for competence,
which is manifested by a feeling of being good at something, but also continually progressing
at getting better at that. There’s a need for autonomy. We need to feel that we
have choices in the world and that our choices
leave lasting impressions. And there’s a need for relatedness. What I want to really talk about is this need for relatedness and how that connects to identity. All 3 factors are important
and it turns out that these are important factors,
these are important needs to be satisfied in any sort
of self improvement paradigm. But they’re also needs that match with, that correlate well with the best and most popular video games. In that, games that satisfy
these needs for the players tend to be the most popular. So how do we do, how do
we design for relatedness? How do we put that in a therapy game? The first thing is, look
at the players’ needs. Don’t look at what you want to design. Look at what the player
needs, relate to the player. The second thing is and
this is more important, don’t make the player relate to you. Don’t say things like, I’m sorry, you know budgets how they are, we just can’t put a female
avatar in as the protagonist. Don’t make the player
relate to your condition if you want them to be
immersed in your environment. So who are we relating to
when we design therapy games? It could be lots of people,
it could be people who have experienced a trauma. It could be people with disabilities. It could be people who
can’t afford treatment. And it could also be people
who can’t adhere to treatment. Many times, there are, lots of cultural factors that affect who has access to therapy. And because people can’t
access and afford it they’re not getting
the care that they need and the care that they deserve. And video games are a low cost option, for being able to access that. But in order to connect to that person, you have to understand what
is it about their condition. And sorry about the font thing there. What is it about their condition that makes their condition unique? So I want to go through a few
examples of what we’ve done in our video game design to
try to trigger relatedness and to try to connect to the user. And these are really just
simple things you can do when building video games for therapy. The first thing is give the option, give the player options
to be like themselves. Whether it’s avatars or environments or whatever it is about the
player that your designing. Make them feel like they have
a world that they belong to. So if you give them avatars, of different body shapes
and skin tones and genders, that’s really important because then they feel like they
belong in the world. And not just that, but give
them the option to choose and to change their character,
change their avatar. Genders change, identities change. They can change frequently, they can change over a period of time. Don’t gate that change,
that ability to change behind things like, oh, you
have to spend 10 dollars in real world money if you want to change the gender of your character. Don’t make them spend in-game currency to change the gender of their character. Doing that alienates who they are, makes them feel like they
don’t belong to the world. And it’s not that you have
to get everybody included, but you have to reach out
and show the user that the world that you’re trying to create, the virtual environment, is for them. They belong, they are
home and they are safe. Second thing you can do is
design tasks that empower. So, when I talked about
the ADLs, the IADLs rather, we talked about, you know,
putting away groceries. That’s kind of a gendered
activity for some people. So, what are equivalent
activities that you could do, that maybe aren’t as gendered
or maybe don’t trigger those emotions in people. And one of them is, taking care of a pet. When people have acquired an injury, particularly later in life. One of the biggest
motivators for getting back and getting well is that people don’t want to lose their pets. So we, in this particular
game, our Stroke game, we put a puppy in there. And so we have a bunch of activities that are built around
taking care of the pet. Feeding it, giving it
a bath, letting it out. And more than that we
actually put 6 puppies into the game and you
can go and adopt one. So you actually get to
pick which puppy you like. And then beyond that we also
allow them to change the puppy, so if the puppies misbehaved they can just go and get a new one. (audience laughs) Not really, we do allow them to change. But even this is not
really that, this is not this task is not immune
to cultural insensitivity. If you were Muslim for example, this might be an alienating experience. So, one of the things that we do is that we make sure that our tasks, we give them choices, we give them options to not do that task. Third thing to help relate, design challenges that are familiar. Make them feel like, the virtual world is something that will help them get
back to their lives. Or join the world of everyone else that is not affected by the condition if they choose to do so. We have built a video game that’s supposed to help people stop smoking. So we have a work environment, in which the user has to
try to combat smoking urges. Which actually triggers for
their nicotine addiction. Which is actually a very
specific form of therapy known as Cue Reaction Therapy. So by doing that in a familiar environment versus an abstract virtual environment, you are able to connect
more with that user and provide them with a more realistic and relatable experience. Same thing, we have gardening experiences. So rather than trying
to put away groceries, you’re actually growing your own food. And by giving the person
the ability to feel like the world that they’re in is connected to the choices
that they’re making, they can pick which groceries or which vegetables they
harvest, for example. Makes them feel more like they, again makes them feel more
like they belong in the world. So there’s some complications with this. Almost no task is gender
neutral, for example. Almost no situation is
familiar to everybody. So it’s really hard to, to try to, there’s no sort of universal design. You have to look at all of your users and try to make sure you’re
not excluding anybody. And so the choices are, the
solutions are, offer choice. Give the users the ability to choose what they are going to do. Give the users abilities
to choose their therapies and to choose which
actions they want to take and which actions they
are not willing to take. Let them repeat actions that
they have more comfort with. Most importantly, be
diverse in what you care for and what you create. So don’t assume that they’re going to relate to the environment
that you’ve created because it’s familiar to you. Finally, I’ll leave a few
minutes for questions. But the other thing
that is really important because these devices or these video games that we create, when we
create them for therapy, these are medical devices. These are not video
games for entertainment. And when you work in the medical space or when you’re creating things, that are supposed to
help people’s well being, there’s an oath that you should take. Doctors have to take and that is do no harm. So, even if your choices can’t be perfect, you have to make sure that
the choices you’re making, that the things you’re
asking your users to do are not going to harm them. So, that’s it. There’s a few minutes left for
questions if there are any. Thank you very much. (audience clapping) (upbeat music)

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