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The future of games and health: towards responsible interaction design

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The future of games and health: towards responsible interaction design

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Content THE FUTURE OF GAMES AND HEALTH:
TOWARDS RESPONSIBLE INTERACTION DESIGN
by
Patrick Lemieux Bender

A Thesis Presented to the
FACULTY OF THE USC SCHOOL OF CINEMATIC ARTS
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF FINE ART
(INTERACTIVE MEDIA – GAMES & HEALTH)

! May 2019
Table of Contents
2
3
4
5
6
7
12
Simone Weil – Every Separation is a Link 13
Borges – The Human Interacted with the Computer 17
Rethinking The Nature of Design 21
Games and Health - Areas of Significance 24
Designing and Identifying Clinically Significant Games 24
How Games Work in Tandem With Other Digital Artifacts 28
Discovering Unique Affordances of New Technologies 29
Bibliography 33
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T able of Contents
Acknowledgements
List of Figures
Abstract
Note to the Reader
Boundary Problems
Identifying the Self and Other Through Technology
Acknowledgements
I wish to thank all members of the Creative Media & Behavioral Health Center.
!3
List of Figures
Figure 1: Internalist HCI Diagram 9
Figure 2: Cognitive vs Enactivist Diagram 10
Figure 3: Sentence Generator with Random Input 19
Figure 4: Sentence Generator with “Human” and “Computer” as Input 21
Figure 5: Bioshock’s Hacking Mechanic 25
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Abstract
The role of technology in our lives has outpaced our understanding of its impact. Digital artifacts
are irreplaceable elements of the lives we live. Post-cognitive thought has embraced the
possibility that these artifacts should be granted a more important status than mere property.
Instead, they might be considered extensions, or even expressions, of agency. Game designers
are in the business of creating interactive systems that have significant degrees of meaning to us,
so they are in a unique position to command a shift towards responsible interaction design. In
this piece, I try to chart out how the sensibilities of game designers can assist in creating digital
artifacts that maintain the dignity of users. The solution I offer is to take insights from the field of
narrative medicine and use phenomenological reflection as a legitimate source of qualitative
data. These reflections can help disclose the relationships we have to technology and reorient
design frameworks away from an overly formal approach.
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Note to the Reader
I should first wish to address the reader very plainly concerning the document you are about to
read, whenever you may be doing so. I am the first (prospective) recipient of the MFA in
Interactive Media & Games with a concentration in Games and Health from USC’s School of
Cinematic Arts. Though this specialization had existed for some time, nobody had pursued it. I
myself knew little of the opportunity and never imagined that I’d have gone down this road. You
might, along the way, excuse the purple prose. I am not holier than thou, but I do feel
passionately that the relationship between our concepts (game and health) are not treated with
sufficient sophistication or clarity. The main purpose of this piece is to compel a broader
discussion about what the future of games and health ought to look like. Readers of the future
will determine whether we were on the right side of history.
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Boundary Problems
I have found that any honest discussion about games must be preceded by general commentary
regarding the role of interactive media in our lives. Digital artifacts have arrived only fairly
recently for human beings, and so it is not immediately clear what role they play in
manufacturing identity. In the year 2019 there are legitimate theoretical frameworks that cast the
relationship between brain and software as a very intimate one (Clark, 2008; Noë, 2015; Pitts-
Taylor, 2016; Prescott & Verschure, 2016) While traditional understanding of human cognition
once fixated on the brain as a computational device, more recent depictions of cognition have
begun to remove sole responsibility from the brain. The body is not merely the channel between
the world of information and the computational brain. Instead, situation-specific interactions
between brain, body, and world give rise to human experience.
The fact that culture and technology play crucial roles in our lives may appear somewhat trivial.
However, the nature of digital tools requires us to consider them as unique. Digital artifacts are
vastly more complex tools than those of our ancestors (Hoffecker & Hoffecker, 2018). The
technology we currently have on offer, depending on your theoretical framework, operates as the
expression of human agency, or the cultivation of human development at a much faster pace than
the tools of our ancestors. We are bound to them, sometimes unwittingly and usually without
choice. Those who are in the business of making choices about digital artifacts for others – who
consumes them, how they are created, what they are intended to do – are actually in the business
of human development.
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Because these digital artifacts can provide realtime feedback of great variety, they are a new kind
of tool that we have come to rely upon. The loops create normative dependencies between flesh
and hardware. We will have adopted them into our daily existence in a way that distinguishes
them from more basic tools.
Such cases are putative examples of extended cognition, whereby our mental lives extend
beyond the brain and include the body and world. Digital artifacts are exemplary of these kinds
of extensions. For example, phones have been considered external memory storage, and Tetris
has been explored as an example of extended decision-making (Clark, 2008; Clark & Chalmers,
1998). Players do not deliberate in their heads where to drop zoids. Instead, the cognitive effort
is outsourced to the software itself. The decision-making process, if we are to draw a circle
around it, includes the brain, the body, the hardware, and the software. This is inspired by the
fact that mental rotation of the zoids is much more cognitively costly, and so recruitment of the
interface and software is a more efficient way to “decide” optimal solutions.

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Figure 1: Internalist HCI Diagram

This small possibility has great implications for how we understand human-computer
interactions. At the very least, if human agents – or their mental faculties – are spread into virtual
worlds, then we have to address whether existing HCI theory is consistent with this. The figure
above is an illustration of a game design framework featured in Rules of Play (Salen &
Zimmerman, 2004). We can use this triad to wedge the difference between an internalist
understanding of how Tetris is played, and an externalist depiction. The method in Figure 1
places a clear boundary between the decision-making capacities of the user, the action of the
user, and the feedback of the software.

Externalist positions would instead remove the internal deliberation. The decision-making
process is visualized through the play of Tetris itself. From an extended cognition point of view,
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the output of the game is not merely a response to the input of a player. Rather, over prolonged
exposure to the interactive system, the “output” begins to function like a mental space for the
player to think in. It would not be importantly different from visualizing in one’s head where to
drop the zoids. Frameworks that do not even consider this reality rob designers and players of
their digital agencies. Regardless of who you are, if there is an interface between you and a
digital artifact, you should consider the boundary between “you” and “it” permeable. Tetris in
action is merely somebody’s thought process. And for that, we ought grant it a more personal
status than mere expendable property. The boundary of what and where the agent is is at all times
fluid and negotiable.
Figure 2: Cognitive vs Enactivist Diagram
1

This positions digital games as a kind of digital artifact that is held in contention: we simply do
not have a way to determine the reasonable rights people ought to have with respect to these
This image is taken from (Prescott & Verschure, 2016). While enactivism is different from extended
1
cognition, they both fit within the ambit of the Pragmatic Turn that the volume concerns. That is, each of
these theories is interested in challenging cognitivism in different ways. For our purposes, we need only
explore (but not commit to) some of these theories in order to understand the design theory I am
opposing.
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types of tools. You no longer function as a digital consumer. You are digital agent whose mind is
not locked away in the body, but rather spreads like a sphere of influence across physical and
digital.
2
In Figure 2, we see two different models. The one on the right considers agency as an act of
creation, not a sensing-thinking-acting thing (as seen on the left). As such, when our
technological worlds become fixtures of that self-constitution cycle, we become accountable for
the kinds of devices we put in front of people. There is already precedent to look backwards in
time at the tools of our ancestors to make claims regarding their cognitive capacities (Sutton,
2010). Some endeavor under the banner of “software archaeology” to examine these tools and
work backwards to reveal insights on our ancestors’ brains (Dennett, 1986). In our cases, with
digital artifacts upon which we depend in a more realtime basis, we might suspect that our
interactive devices do not merely buttress the faculties we already have, but instead either
facilitate existing cognitive tasks, or create new kinds of cognitive tasks. Game designers are the
architects of this future.

See discussions in (Barrett, 2011) for a Field Theory account of man, inspired by Heidegger. For
2
discussions concerning the spread of the self in a contemporary and medium agnostic fashion, see (Clark,
2007)
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Our agency is not easily contained across digital experiences, so we might be compelled to
rethink the role of the designer and the user in digital contexts. Given that our topic concerns
health and wellbeing, it would make sense to identify any parallels to caregiving frameworks.
One of the problems that nurses have in the 21
st
century is identifying ways to care for patients
across technologies, which directly recruits the skills of designers (Sandelowski, 2002).
Narrative Medicine is a growing field that uses literature, narrative, and storytelling to help foster
opportunities to care for patients in more holistic ways (Charon, DasGupta, Hermann, Marcus, &
Spiegel, 2016).
However, this issue pertains to the nature of care in general, technological or otherwise. The use
of narrative in caregiving is sometimes compromised by formal systematization of the role of the
nurse (Benner, 2000). Feral formalization can obstruct opportunities for intimate relationships
within the care giver- care recipient paradigm:
“These insights are enhanced and clarified by late Heidegger’s critique of technology as having
the potential of turning human beings into resources. Late Heidegger warns that the kind of
ordering characteristic of technology, which he calls enframing, causes us to experience
everything as resources in a system that is to be enhanced and controlled. Such enframing may
prevent us from seeing and relating to the concrete other and are the relational dangers that
nurses face daily in their efforts to care (294).”
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Identifying the Self and Other Through Technology

She goes on to discuss how the nursing paradigm is infringed upon by a technological ordering.
Successful opportunities for care exist at a relational level that includes a narrative, holistic
understanding of the other. Systematization of how we conceive ourselves as caregivers can feed
back into how we self-identify as agents. As such, those in games and health need to understand
the larger apparatus cultural and technological apparatus within which we make games. Game
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design should be able to meet this demand, as they are in the business of meaning-making and
enchanting value in digital environments. Good designers are, ultimately, good players insofar as
they can bend systems towards their own purpose. If we do not let designers be players and
recognize the larger technological contexts in which their designs operate, then we lose sight of
responsible interaction design.
In order to facilitate new kinds of frameworks to understand our relations through interactive
systems, we need to use technology responsibly. This pertains to both healthcare proper, but also
any instance of digitally-mediated care, which would be a point of intervention for game
designers. However, because it is not clear how one is positioned in relation to another across
virtual worlds. The following narrative pieces, and their exploration, can help to guide us.
Simone Weil – Every Separation is a Link
Nursing frameworks use the term “presence” to refer to a variety of ways to be there with
another person, the most significant among them being a transpersonal experience that breaks
See (Dyer-Witheford & De Peuter, 2009) for a horrifying account of the relationship between the
3
entertainment industry and academic institutions. It appears they are both complicit.
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down the boundary between two individuals (Osterman & Schwartz-Barcott, 1996). These cases
of being with another person are holistic in nature. The role of the body is crucial in creating
these instances of care. Being with another person in an embodied fashion is like a dance
between two individuals (Gallagher, 2014). Absent the flesh, the more spiritual moments of care
are ostensibly not possible to achieve.
Even if this is partially true, this does not mean that technologically-mediated opportunities for
care are unimportant. In fact, separations across virtual environments that do not feature all of
the physical components of interaction may take on a unique characteristic. The distance does
not need to diminish the quality or meaning of the interaction. In fact, Simone Weil claims that,
in a spiritual capacity, connections to the divine are always mediated (Metaxu is the term she
uses)(Weil, 1997)
“Two prisoners whose cells adjoin communicate with each other by knocking on the wall. The
wall is the thing which separates them but it is also their means of communication. It is the same
with us and God. Every separation is a link (145).”

What she alludes to is a kind of person permanence. Our access to others does not need to be
diminished across space or time. The presence of another psychologically is a measure of a
cultural disposition that precedes one form of interaction. This has been described as the
distinction between mode and sense of presence in virtual reality (Zhao, 2003).We may come to
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know others through specific mode of interaction (like the telephone, or through a video
conference). But we may also feel the sense of another in a completely psychological fashion.
When we consider every separation a link, we rely less on specifically designed interactions
between individuals, and instead focus on the ways we can see others in an emergent fashion.
This addresses how we can come across others in unplanned instances, but it also speaks to the
way that designers are not necessarily separated from their users. That is, you can very easily
observe how the design of a system considers the wellbeing of another. Such systems are
legitimate instances of care, even if they are not materialized right in front of you. Just because
you do not know your user does not mean they will not come to you. This compels us to consider
how interaction design should not ignore this permanent link between designer and user.
Person permanence cuts both ways. The designer is directly perceivable in their creation. But so
too, we can observe the traces that others leave through the impacts they leave in a space. These
digital traces are not incidental, but legitimate acts of agency across virtual worlds. How or when
we come into contact with others cannot always be prejudged or even predicted by the kinds of
design you implement. The following case can help illuminate what is at stake:
A father and son play a racing game together. The son grows up, and the father passes away.
Years later, the son starts the game up and discovers that a digital avatar of his father remains on
the racetrack. The son races against his father’s avatar, but realizes that beating him would
replace his father’s avatar with his own, since the avatar represents the best racing performance.
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The son decided never to beat his time, since doing so would lose his father’s digital trace
(Riendeau, 2014).
This case is poignant in that it helps visualize the father’s presence in a meaningful way to the
son. The video game console provided an opportunity for the son to have a meaningful social
experience. But digital footprints of these kind exist explicitly or implicitly across many media.
What may distinguish this case from the footprints we may leave on social media (a system
dedicated to social interactions) is the preciousness of stumbling upon something a loved one left
behind.
Different kinds of objects and their contexts can serve as different touchstones to the past. Is the
father’s digital footprint merely a keepsake, or is it properly representative of the father? In what
meaningful way was the father “there” for his son? Can we be there for others without knowing
it? We may deliberately seek to design interactions between individuals, but we must leave open
the possibility that these deeply personal interactions are possible, despite the design. Their
physical absence does not diminish the significance of the interaction. Similarly, the physical
absence of the father does not need to diminish the social component of the son’s experience.
Given the access they provide to others, digital footprints are perhaps integral to design instead
of incidental.
One of the implications is to understand that care is the hallmark of games and health – and this
does not need to be in the flesh, and it may have its own uniquely digital characteristics. You can
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care through your design. Given that we cannot prejudge where and when and how our
creations will play a role in choreographing human behavior, it will be important to recognize
that – at every moment – there are cases where we are in direct contact with another person.
Should not be paralyzing, but rather liberating. It is not that we are always responsible for people
we don’t know, but rather that we come to know each other through design. When you design for
a user, you are extending a hand. When a user interactions with your design, they are reaching
out for it.
Borges – The Human Interacted with the Computer
Just as we must stay alert to how and when others can come into view, we, ourselves, need to
understand how that spread across technology might work. I want to explore the basis of the
rhetoric of human-computer interaction. In service of this opportunity, let us use a short story
from (Borges & Hurley, 1999). Tlön, Uqbar, Orbis Tertius describes a fictive world where
language is used always tentatively, and no direct reference to objective fixtures of a world is
made. And so, as the story suggests, sentence (1) is translated to (2):
(1) The moon rose above the river.
(2) Upward beyond the onstreaming, it mooned.
In this case, we find that (1)[the river] is replaced most reasonably by (2)[the onstreaming].
(1) The moon rose above the river.
(2) Upward beyond the onstreaming, it mooned.
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We also find that the subject-predicate logic of (1) [The moon] subject [rose above the water]
predicate does not neatly match on to the syntax of (2). Indeed it is not as if the grammatical role
of (1)[the river] is replaced by (2)[the onstreaming] cleanly. For at the end of (2), we find an it
that moons. This it is the subject of (2), not the moon. This is to say that static objects - rather
than an “onstreaming”, which lends itself to the transitory status of all objects in this culture - do
not exist. And so we have an answer for a translation practice for the subject. The subject is an it
that performs the function of a noun - there is no moon, but there is that which does moon.
(1) The moon rose above the river.
(2) Upward beyond the onstreaming, it mooned.
And the rest of the translation is meant to capture the general semantics of how the it performed.
How did it moon? The rest of the sentence becomes an adverbial phrase. The syntactic structure
of (2) is to concoct a subject (which we will call Z) that performs an actionable form of (1)’s
subject. The rest of the sentence is an attempt describe how this happened.
(1) X does Y in some capacity
(2) in some capacity , Z does X
The reason we’ve gone down this rabbit hole is to see how “the moon” becomes less of an
emphasis in (2). The description of the event (recall the “deed”), rather than a specific actor
(recall the fictive “doer”) is made more significant. There is furthermore an implicit gap in our
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knowledge - or appreciation for what cannot be said - in (2). What is this “it” that moons? This
third variable Z? I suspect it functions something like whatever is on the other end of our pointer-
finger. It is the target of the gesture. But for our purposes, it is just one step towards breaking the
frame of our language. It has lit up the room in which our language resides.
We can bring the conversation into more concrete terms by following a classic example in
linguistics - a phrase originating in (Chomsky, 2014). In order to illustrate a distinction between
syntax and semantics, this sentence follows the syntactic structure of Standard American English,
yet inserts words to create a sentence that is ostensibly nonsense.
Colorless green ideas sleep furiously.
This does not mean anything, right? Well to some linguists, no. But to an artist, why not? Below
is a table of syntactically valid sentences procedurally generated through excel. Each column
functions like a part of speech in Standard American English. The words are pulled from lists I
pulled at random from the internet.
Figure 3: Sentence Generator with Random Input
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Surely, this is more of a practice in imagination. If you try hard enough, the sentences above will
produce imagery, or some conceptual narrative that can mean something in a very abstract sense.
(Otherwise, I suspect poetry would never have become an art form.) To the extent these are
useful ways to talk, I can understand the motivation to split semantics and syntax. But
nevertheless, a deliberate breaking of our linguistic system can embrace meanings that we often
cannot see. As such, let us revisit the obtuse syntax of Tlön and explore how we can use
language to elicit new meanings out of the phrase “human-computer interaction”.
(A) The human interacts with the computer.
(B) Betwixt through the state-machine, it humans.
It is this green territory where we find our ethical dilemma. In what capacity does the human
relate to the computer? Interact with? Well, this might make sense for the logic of (A), since
there are discrete entities interacting. There is indeed a doer. But (B) focuses on the deed. And
what exactly is the deed? When this it “humans”, how does it do it? How do we wish to translate
it? In the case above, (B) suggests that the “it” that “humans” has a more intimate relationship
with the computer. Rather than a betweenness, there is a “throughoutness”, or an “all-
encompassingness”.
The deed is the event - the unity of two parts of a system. But Tlön lets us parse out what is
important about the deed - the unity - the whole system before it is carved into two. One of the
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central opportunities for this adverbial phrase is that we can reflect on how the human-ing is to
be done - (as is the function of an adverb) temporally, spatially, or otherwise qualitatively. Would
flipping the human and computer roles do us any good?
(A) The computer interacts with the human.
(B) Despite the mammal, it computes.
Is this too pessimistic? Generative nonsense, perhaps. But let us move one step forward. Plug in
“human” and “computer” for all the relevant nouns in our sentence generator. You might also
replace either noun at your own convenience to help make sense of the output. But don’t let the
computer tell you what to do.
Figure 4: Sentence Generator with “Human” and “Computer” as Input

In each of these cases, literature served to expose some element of what the nature of design is.
Just as narrative helps to expose new opportunities for care, stories like those above can help to
probe new ways to understand the nature of design. This is partially compelled by what appears
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Rethinking the Nature of Design
to be a lack of design reflection in most game design frameworks (Patil et al., 2017). The Queer
Game Studies movement, although nascent, taps into some of these key insights concerning the
intimate connection built between flesh and hardware, and the subsequent identity formation
process (Ruberg & Shaw, 2017). I will not pretend to do justice to this field, but I share the
concern that existing game studies and design frameworks risk ignoring an existential component
to interactive systems. Part of this involves the recognition that our designs feed back into who
we are in the first place. The qualitative reporting or how this affects us is a key ingredient to
exploring these effects.

Consider, however, the popular MDA (Hunicke, Leblanc, & Zubek, 2004). Its depiction of
design is considered to be an activity that bears no consequence on the lived experience of those
involved. Designers and users operate like fixed cogs in service of the event of game design.
Such events are not understood as expressions of the self, or acts of discovery and meaning-
making. If rampant formalization can obstruct caregivers’ relationships to their patients, then the
4
designer-user dynamic may suffer the same fate. How can we explore design pedagogy that
encourages holistic designer-user relations? How we understand design in the first place can lead
to significant downstream effects on the possibility for games to help or hurt us.
When we talk about letting designers reflect on their creation, we are talking about letting
designers explore in an informal manner their longterm associations with interactive systems.
Formal methods can assist in guiding our design via best practices for a finished product. But
For an extraordinary look at creative uses of technology that embrace the feedback loop between design
4
and human development, see (Sha, 2013).
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these attempts cannot predict how our creations will feed back into our self-understanding and
play a role in our identities as human beings. This is a legitimate source of qualitative data that
we risk ignoring strictly by putting too much faith in the formal approach to design. Those
qualitative reports will come from thoughtful analysis of relationships to tech, as well as actively
reinterpreting the nature and role of design.
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Games and Health - Areas of Significance
In what follows I hope to show just a few examples of how game designers can assist in creating
responsible interactive systems.
Designing and Identifying Clinically Significant Games
One misnomer to be addressed is the idea that a game not for health does not fit squarely within
the bounds of a clinical application. We know enough about the relationship between exercise
and physical health to make certain broad claims about how movement-based games can help
individuals. We do not know as much about how digital artifacts with controller-level input
concern the health of an individual. There is evidence that off-the-self titles have social,
motivational, and emotional benefits, though most of the studies focus on the cognitive benefits
(Granic, Lobel, & Engels, 2014). One of the difficulties noted, however, is in localizing which
features of a game actually promote specific benefits. That is, the studies suggest that discussions
concerning games and health need to specify which kinds of games, say at the genre level, do
what.

In parallel to this approach, it is worth noting that with-genre differences can be quite profound.
These differences will appear only through exposure to the game, which might require
experiential documentation of what the game feels like to be played. Designers should be able to
attend to the acute changes in what the game demands of the player, so as to shed light on what
kinds of actions will be elicited from the player. If you look closely enough at games of the same
genre, you will still find that different kinds of tasks are demanded of players within that genre.
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Sometimes these subtasks are obvious, other times they are not. Bioshock is a first-person
shooter title that demonstrates a clear case of a game within a game.
Figure 5: Bioshock’s Hacking Mechanic
5
Within some encounters in Bioshock, the player stops playing a first-person shooter and begins
to play a puzzle game. In the context of the broader Bioshock experience, this puzzle game
permits the user to hack machines that can fight at the behest of the player. In ordinary contexts,
hacking might just be the push of a button, but here it serves as a brief interlude between
otherwise generic tasks demanded by a FPS.
This serves to demonstrate that games are bundles of different cognitive challenges. From the
top-down, we can classify genres of games to help predict which can serve specific needs. From
the bottom-up, from a designer’s perspective, it is clear that within-group differences need to be
Image taken from IGN from https://www.ign.com/articles/2010/02/01/bioshock-revisited?page=2
5
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determined to suss out meaningful separations. Designers should be able to pick out what tasks
are being asked of the player, and estimate what kinds of resources they are drawing upon at any
given time. This means that if somebody were to ask the kinds of cognitive tasks that compose
an encounter in Bioshock, the sub-activities would need to be illuminated. In this case, it is clear.
In other cases, where there are no clear boundaries between cognitive tasks, it requires greater
attention to mechanics.
This, then, proposes the additional question of what cognitive benefits emerge when players have
to stop playing one game and pick up another. This is the phenomenon of task-switching. Menu
navigation and planning are pandemic across most game genres, and though these are not puzzle
games, they still are reflective of decision-making processes that can pertain to a series of long-
term or short-term goals. In consequence, there are mechanics to be identified, but also how that
mechanic is embedded within a larger task. The designer’s job here would be to excavate from
another’s design what kinds of demands are being asked on behalf of the player.
As such, another approach to designing games for health would be to start from scratch. That is,
rather than excavate clinically significant mechanics from existing digital artifacts, the design
process starts from the ground up with clinical significance in mind. This process results in
closed loop video games (CLVG) (Mishra, Anguera, & Gazzaley, 2016). This approach involves
a participatory approach that designs for very specific needs from the start. Participatory design
of this kind would require neuroscientists, therapists, designers, etc. to convene from the ground
up to target specific measurable effects. This requires designers to interface with any expert that
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can contribute to the creation of the design. As such, designers will need to integrate the insights
of others and play a collaborative role.
Digital artifacts created through mixed-methods approaches like these are less common, and
some early trials to reduce anxiety in children suggests that CLVG and off-the-shelf titles may be
just as effective in anxiety reduction (Schoneveld et al., 2016). Nevertheless, one advantage this
approach has is that it can be tailored to a particular user group. Rather than attempting to
identify mechanics that are just good in general, working for specific clinical populations with
specific concerns permits a more targeted approach. The problem is that, while top-down design
has issues determining what is clinically significant, bottom-up design’s great challenge is
creating digital artifacts that are clinically significant.

Virtual reality (VR) is increasingly being used for the purpose of sensorimotor rehabilitation
(Weiss, Keshner, & Levin, 2014). One promising area for CLVG are immersive virtual
environments that promote health on the basis of the moving body. This also requires that
designers become somewhat knowledgeable in the domain they are working in. Designers play a
role in what needs to be a participatory approach to revealing healthy tech-flesh relationships. In
such cases, designers may need to work directly with and learn from the clinical population they
are designing for. While this is may be an over case of designing with responsibility, the same
respect should apply to any audience you are designing for.
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How Games Work in Tandem With Other Digital Artifacts
Sometimes it is ambiguous how mechanics/games are facilitating wellbeing. When systems
become so complex that we cannot identify which mechanics serve whatever purposes, we can
look to the player reports concerning the game’s effect. Preliminary research at the USC Creative
Media & Behavioral Health Center concerning Dark Souls suggests that answers will actually
come from player interviews. We have begun to transcribe and code a series of interviews with
Dark Souls players to determine what role the game played in helping with their depression.
One of the difficulties we have is that their discussion is idiosyncratic – their narrative of the
game requires familiarity on behalf of the researcher. But given that complex nature of the game,
avenues to success are often inscrutable. As in the case of Bioshock, some familiarity with the
game in question can help assess what it is players are discussing. For games that are particularly
idiosyncratic, high participation with the game and community may be helpful.
Early coding of the interviews also suggest that senses of accomplishment are a big factor. This
possibility is at least partially informed by the organic social communities that were formed by
journalists who were attempting to review the games without an existing online resource
(MacDonald & Killingsworth, 2016). In this case, the game’s mechanics facilitated social
interactions and culture formation beyond the game itself. The role that this community plays
depends upon the avenues of communication that players have. This suggests that even games
that do not have explicit multiplayer components can still foster social communities oriented
around the game. The upshot is that we cannot prejudge how specific mechanics will, in certain
!28
contexts, affect players. To solve the tasks of the game, players may recruit extra-ludic systems
that develop in response to the game in the first place. What players did in order to accomplish
their tasks may be outsourced from the game itself.

One approach, then, is to parse out the existing systems and work backwards from existing
content. This may involve different strategies to determine specific mechanics, the contexts of
those mechanics, as well as the abilities recruited outside of the game proper. It can be
ambiguous what a player did to solve a problem. It is the designer’s job to determine what the
player did in order to progress in a game, though this may involve systems outside of the game
itself.

The final path forward for games and health will be a discovery process that approaches health
applications at the medium-level, rather than on the content level. Games can be implemented in
a number of forms, and with the proliferation of new media such as mixed realities, it is pertinent
designers adopt whatever role necessary to gain a grip on the unique affordances of the medium.
I believe this will come from experimental approaches that involve self-reflection, as doing
otherwise would prejudge the kinds of affordances available. Part of the job of the designer, at
least for the purpose of identifying recognizable health benefits, is to collaborate across
disciplines, work closely with users of different types, consider the phenomenological reporting
of the players, consult the conditions around which games are being played, etc. None of these is
part of the formal training of game design, but designers who want to get involved for games and
!29
Discovering Unique Affordances of New Technologies
health will want to consider interdisciplinary approaches and adopt different roles than is
expected. Having agency in a new technological domain may expose important revelations about
that medium, which may in turn facilitate new uses.
I will address how this method was crucial in framing an understanding of what uniquely VR-
mediated social interactions may look like. I had the luxury to live in these spaces for a project at
USC’s Locomotor Control Lab, which involved the use of VR to create movement-based games
for Parkinson’s rehabilitation. However, the kinds of social interactions – or the felt presence - I
experienced had very little to do with what was intentionally designed

The salience of others was so profound, but it did not feel like the social encounters I’d have in
physical space. The unique temporal structure of these interactions had me feel the presence of
others through an absence, almost like grief (Fuchs, 2018). The grieving process is partially
characterized by a loss of another’s living embodiment in a space. And to leave the reality behind
and embrace the one without your loved one is to actually have gotten over the loss. Despite not
!30
Experiences in VR do not need to be dressed up to be pretty. That is, when you approach a VR
experience with just a plane below and a skybox above, any addition to the space is poignant.
The virtual space in which I would prototype would populate with my ideas, others’ advice, and
the remnants of others having gone through the experience. The kind of social experiences I was
having were incidental to the goal of the space, yet were consistent byproducts of merely being
in a shared virtual space.
actually being there in an embodied fashion, you can still feel the presence of others through
their glaring omission. But in VR, I had no occasion to grieve, yet I did have access to this
second reality. The virtual space functioned like a memory, nearly like the world you leave
behind after the grieving process. In fact, I was trying to merge two realities (physical and
virtual) in an embodied fashion, but I wasn’t losing anything. In fact, it was a kind of added
value. I was gaining virtual access to those from whom I was physically separated.
But I found that most conventional uses for VR – at least socially – appeared not to embrace this
spiritual access we can have to each other. When I lived in and designed in a space with others,
the culture that formed was our own. The kinds of social experiences common to VR right now
are in social neuroscience (Parsons, Gaggioli, & Riva, 2017; Slater & Sanchez-Vives, 2016), and
one of their primary interests is ecological validity. The hope is that experiments can be run on
individuals with stimuli that more closely resembles the situations participants would experience
in the real world. VR provides the opportunity to tap in to our embodied experience. Ecological
validity is a fine pursuit, although it remains an empirical question how successful VR will be in
emulating the important features of physical environments.
Additionally, most cases of VR include a user who hasn’t really been in VR before. They are
instead seeing the end product of somebody else’s design. After the novelty effect of the platform
wears off and you spend time designing your own spaces, the unique phenomenological
character of the experiences open up. Virtual objects do not need to reflect a physical
!31
counterpart. Instead, they may be appreciated as unique and different, but no less important
(Chalmers, 2017).
As mixed realities technologies become more commonplace, we will need to determine what
roles we want virtual experiences to play in our lives. Very likely the experiences we have in
physical reality will feed into our experiences in virtual reality, which will feed into our
experiences in augmented reality, and so on. I suspect it will ultimately be unimportant which
piece of technology we are using, as we will be denizens of many different realities. However,
this must come from having the agency to decide in the first place. If we use only the designs of
others, we lose opportunities to flourish and permeate across virtual spaces. And when we are
privileged enough to design for others, we must respect the dignity of our users. We must be
there for them through our design.
!32
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Abstract (if available)

Abstract The role of technology in our lives has outpaced our understanding of its impact. Digital artifacts are irreplaceable elements of the lives we live. Post-cognitive thought has embraced the possibility that these artifacts should be granted a more important status than mere property. Instead, they might be considered extensions, or even expressions, of agency. Game designers are in the business of creating interactive systems that have significant degrees of meaning to us, so they are in a unique position to command a shift towards responsible interaction design. In this piece, I try to chart out how the sensibilities of game designers can assist in creating digital artifacts that maintain the dignity of users. The solution I offer is to take insights from the field of narrative medicine and use phenomenological reflection as a legitimate source of qualitative data. These reflections can help disclose the relationships we have to technology and reorient design frameworks away from an overly formal approach.

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Asset Metadata

Creator Bender, Patrick Lemieux (author)

Core Title The future of games and health: towards responsible interaction design

School School of Cinematic Arts

Degree Master of Fine Arts

Degree Program Interactive Media (Games and Health)

Publication Date 04/30/2019

Defense Date 05/08/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag embodied cognition,extended cognition,Games,health,narrative medicine,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Wixon, Dennis (committee chair), Fullerton, Tracy (committee member), Watson, Jeff (committee member)

Creator Email patrick.L.bender@gmail.com,pbender@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-160544

Unique identifier UC11660083

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Legacy Identifier etd-BenderPatr-7361.pdf

Dmrecord 160544

Document Type Thesis

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Rights Bender, Patrick Lemieux

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Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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