ABOVE WATER: An Educational Game for Anxiety

Abstract

We 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.

Full text

ABOVE WATER: An Educational Game
for Anxiety
Rina R. Wehbe
HCI Games Group, Games
Institute and David R. Cheriton
School of Computer Science,
University of Waterloo
Waterloo, ON, Canada
rina.wehbe@uwaterloo.ca
Diane K. Watson
TouchLab, Games Institute and
David R. Cheriton School of
Computer Science, University of
Waterloo, Waterloo, ON, Canada
diane.watson@uwaterloo.ca
Gustavo F. Tondello
HCI Games Group, Games
Institute and David R. Cheriton
School of Computer Science,
University of Waterloo
Waterloo, ON, Canada
gustavo@tondello.com
Marim Ganaba
HCI Games Group, Games
Institute, University of Waterloo
Waterloo, ON, Canada
Melissa Stocco
HCI Games Group, Games
Institute, University of Waterloo
Waterloo, ON, Canada
Alvin Lee
HCI Games Group, Games
Institute, University of Waterloo
Waterloo, ON, Canada
Lennart E. Nacke
HCI Games Group, Games
Institute and David R. Cheriton
School of Computer Science,
University of Waterloo
Waterloo, ON, Canada
lennart.nacke@acm.org
Permission 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.
ACM 978-1-4503-4458-6/16/10.
http://dx.doi.org/10.1145/2968120.2971804
Abstract
We 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 Dis-
order 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 assess-
ment strategy to study the game and determine its effec-
tiveness as a game for health. The game is designed to
educate non-institutionalized individuals with clinical anxi-
ety and panic disorder. Potential players may be diagnosed,
seeking intervention information, or a supportive friend.
Author Keywords
Game for Health; Psychology; Mental Health.
ACM Classification Keywords
J.3 [Computer Applications]: Health; K.8 [Personal Comput-
ing]: Games.
Introduction
The game Above Water is designed to educate players
about generalized anxiety disorders and panic disorders.
Potential players could have a clinical diagnoses, be seek-
ing information about a suspected problem, or playing a
supportive role in another individual’s journey to health.

The game is not designed to be a treatment itself, but in-
stead provides information that may empower individuals to
seek treatment by creating awareness about different op-
tions, and encourage conversation between players. The
game acknowledges that the effectiveness of treatments is
personal to each individual and focuses on treatments as
pieces of a treatment plan that contribute to better overall
health and wellness.
Understanding Mental Health
Figure 1: Life Goal cards
represent some of the player’s
personal goals, reflected in their
in-game goals.
Anxiety Disorders, according to the Diagnostic and Sta-
tistical Manual of Mental Disorders IV (DSM-IV), refer to a
few different disorders including Generalized Anxiety Dis-
order, Panic Disorder, Phobias, Social and Separation Anx-
iety Disorders. Disorders are pervasive and disrupt daily
functioning; in other words, they are not the typical worry
or anxiety faced by a healthy individual. Anxiety caused by
Anxiety Disorders is often disproportionate to the cause,
extends over a long period of time, and can disrupt daily
functioning [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 afflicted
person to experience ongoing daily anxiety, which can be
disruptive 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 feeling
anxious, restlessness, or feeling on-edge [7].
Panic Disorders are characterized by the onset of panic
attacks that can be triggered or appear randomly. Panic at-
tacks are a combination of physical and mental symptoms
that overwhelm the person. Although experiences with the
disorder 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 Overview
The following types of treatments or strategies for dealing
with anxiety will be presented to players on the treatment
cards. We offer a brief conceptualization of each treatment
or 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 Cognitive
Reappraising [3]. Additionally, everyday life changes such
as the importance of exercise [4], avoiding caffeine [7], as
well as relaxation techniques [6] are emphasized. Activities
in the digital component of the game act as an introduc-
tion to self-help methods. Additionally, links are provided to
online information from trusted resources on the accompa-
nying mobile application.
Informing the players about possible treatments is only half
the battle; access to therapies can often be the next big
challenge. The digital part of the game is also designed
to 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 research
places to obtain treatment from a trusted organizations.
Gameplay
Above Water is a game that players play with physical cards
and 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/

Materials
The game is played using the Above Water card deck and
players’ personal devices. In the deck there are four card
types: life goals, anxiety, treatment, and share cards. There
are 61 cards in the deck: 24 Life Goal cards, 20 Anxiety
cards, 12 Treatment cards, and 5 Share cards.2The game
is designed to be played with four players.
Figure 2: Anxiety cards represent
the challenge imposed by anxiety
disorders and can be countered by
Treatment cards.
Objectives
The objective of the game is for players to achieve all of
their life goals while managing anxiety. In this game, goals
take 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 player
must 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 has
started.
End of game
The game ends when the winning condition is met. A player
wins when they have achieved their goals (i.e., they have
collected their chosen Life Goal cards that represent their
objective) and their anxiety counter is at zero (i.e., the player
has no anxiety cards in hand).
Game Mechanics
On 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 be
discarded by using treatment cards.
Life Goal Cards
Life goal cards were designed to encourage players to
think or talk about their personal life goals. These cards
2The 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 goals
to collect during gameplay. The player will announce to
the team which goal cards they are pursuing and tell the
team what they are trying to accomplish (e.g., "I will col-
lect an Education card to represent my goal to do well in
my Games for Health class, and one social card that repre-
sents my goal to make friends with the other students"). Life
goal categories are broad to cover most areas of life goals,
but still give guidance to help formulate their goals. Since
goals in life are often diverse and multifaceted, players must
choose four different life goals from the eight different op-
tions provided. This mechanic in the game facilitates open
communication and asks players to develop their own per-
sonal narrative.
Anxiety Cards
While the players are collecting cards they may unfortu-
nately pick up an Anxiety card (Figure 2). The player’s goal
is to discard all anxiety cards, but they cannot be discarded
without a treatment strategy. If the player’s anxiety counter
goes up it will inhibit their gameplay strategy. For each turn
the player has a full anxiety card counter (5), they will have
a panic attack, where they must discard one card (other
than an anxiety card) and lose a turn. The player’s anxi-
ety card count will be reduced to four cards following the
missed turn, allowing them to play again. This mechanic
was designed to teach players about the dangers of not
dealing with their anxiety and allowing it to progress. It also
is a metaphor for life with an anxiety disorder because it is
pervasive and disrupts everyday functioning.
Debunking Mental Health Myths
This 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 on

it. When players proceed to the app, they will have to de-
termine whether the presented ’fact’ is true within the time
limit.
Treatment Cards
Figure 3: Treatment cards counter
Anxiety cards, some by completing
an activity on the player’s personal
device.
Various treatments and strategies are available for individ-
uals with anxiety disorders. Treatments on these cards are
based on the literature for treatment of anxiety and panic
attacks. In reality, treatments do not all have the same ef-
fectiveness level for everyone. The goal is not to prioritize
different treatments, but to raise awareness of different op-
tions.
Within the game, we have based the effectiveness of the
game 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 that
defines 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 of
therapy requiring a therapist may be able to treat two or
three anxiety cards. Treatment cards can be used at any
moment during a player’s turn. When a Treatment card is
used, it is discarded by the player together with one or more
Anxiety 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 Treatment
card and a Therapy Treatment card in the same turn. How-
ever, only one card of the each Treatment type can be used
per turn, thus the player cannot use two cards of the same
type 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 players
can participate in.
Deep Breathing Application
The 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 Application
The mobile app is used to show a yoga or guided me dona-
tion pose (Figure 4). Players take a moment to stand and
stretch while trying the exercise. The phone assesses the
player’s balance by using accelerometer data. This allows
players to assess how successful they were at the activity
and enables some in-game competition between players.
Share Cards
If a player picks up a Share card (Figure 5) they will be re-
ferred to the app. The app will randomly pick a question
for 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 will
also give players the opportunity to discuss a strategy of
their own. This encourages conversation and personal-
ization of the game. These cards are meant to facilitate
dialogue between players and help them relate their experi-
ences with the information being presented by the game.
The application anonymizes the answers, and hides player
identity. More information is conveyed about privacy and
sensitivity of the game in an upcoming section.

Discarded cards and the Pile
Players will draw cards from the top of the deck and discard
them into a separate pile face up. Once all of the cards are
discarded, they should be reshuffled and made into a new
pile. The game can then resume and progress normally. In
addition, the Group Therapy treatment card will ask players
to reshuffle the deck immediately after being drawn.
Privacy and Sensitivity
Figure 4: The companion mobile
application is used to guide players
through 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 answers
and employs partial presentation of group responses to
protect player identity. Each player is able to answer indi-
vidually on their mobile device; unlike other games, players
do not hand-write answers and cannot be identified by their
writing. Furthermore, question are designed to be indirect
and non-threatening. Additionally, players can also role-play
as a character of their choosing. This is a helpful option be-
cause the player can discuss the feelings and challenges of
the disorder without disclosing personal information, thus
supporting privacy.
Art
The game is designed to be a card game with an approach-
able water-colour art style. The design is simplistic and
meant to avoid provoking anxiety. Colours like blue and
green are used heavily. Additionally, life goal cards are
made to look like rewards to encourage positive thoughts
about 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 the
metaphor of "keeping your head above water". This reflects
the game’s goal to teach coping methods, educate players
about the treatments for the disorder, provide motivation,
and encourage to pursue academic and career goals. This
is especially important because many sufferers of anxiety
do not seek help or understand their disorder as curable
with the adequate treatments [7].
Technology
Above 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 simple
HTML5 enabled website. This allows the game to access
accelerometer data from the personal devices, and be com-
patible with most modern devices without needing to be
developed for multiple platforms. To start the game, one
player must create a game instance that provides a code
for the other players, allowing the game to be synchronized
across all devices. When an interactive experience is trig-
gered, the game master (the player who created the game
instance) selects the interactive experience, and all players
will participate.
Discussion
Collaboration and Narrative Gameplay
The game is designed to be collaborative and foster com-
munication between players. Discussing about mental
health 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 for
anonymization of comments allowing for a more open envi-
ronment for players who may not want to disclose personal
information.
Share cards are part of the collaborative nature of the game
and compliment the narrative game mechanics. Further-

more, Share cards allow for customization and personaliza-
tion through by allowing players the opportunity to create
questions when prompted by the application.
Figure 5: Share cards allow
players to progress their own
narratives or share personal
experiences.
Built-in Learning
The mechanics of the game are designed to teach people
in a natural way by allowing the association of information.
Cards for managing in-game anxiety provide information
for techniques that may be used to help the player manage
their own anxiety in real life, ultimately tying the excitement
of 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.
Acknowledgments
The authors would like to thank Prof. Chrysanne DiMarco,
Raymond A. Mar, Rita Orji, Elisa Mekler, and our reviewers
for their feedback. We would also like to thank Andrew of
the Center Addiction Mental Health (CAMH), and Miriam
from Bloom and Kid’s Help Phone for their feedback. Rina
Wehbe would like to thank the Cheriton School of Computer
Science, University of Waterloo, and NSERC for funding
her research. Gustavo Tondello would like to thank the Uni-
versity of Waterloo and the CNPq, Brazil for funding his
research. 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 for
supporting this research.
REFERENCES
1. Gavin Andrews, Megan J. Hobbs, Thomas D.
Borkovec, Katja Beesdo, Michelle G. Craske,
Richard G. Heimberg, Ronald M. Rapee, Ayelet Meron
Ruscio, and Melinda A. Stanley. 2010. Generalized
worry disorder: a review of DSM-IV generalized anxiety
disorder and options for DSM-V. Depression and
Anxiety 27, 2 (2010), 134–147. DOI:
http://dx.doi.org/10.1002/da.20658
2. TD Borkovec and E Costello. 1993. Efficacy of applied
relaxation and cognitive-behavioral therapy in the
treatment of generalized anxiety disorder. Journal of
Consulting and Clinical Psychology 61, 4 (August
1993), 611–619. DOI:
http://dx.doi.org/10.1037//0022-006x.61.4.611
3. Alison Wood Brooks. 2014. Get excited: reappraising
pre-performance anxiety as excitement. Journal of
Experimental Psychology. General 143, 3 (June 2014),
1144–1158. DOI:http://dx.doi.org/10.1037/a0035325
4. JD Brown and JM Siegel. 1988. Exercise as a buffer of
life stress: a prospective study of adolescent health.
Health Psychology : Official Journal of the Division of
Health Psychology, American Psychological
Association 7, 4 (1988), 341–353. DOI:
http://dx.doi.org/10.1037//0278-6133.7.4.341
5. Peter A Levine. 1997. Waking the tiger: Healing
trauma: The innate capacity to transform overwhelming
experiences. North Atlantic Books.
6. Lars-Göran Öst and Bengt E Westling. 1995. Applied
relaxation vs cognitive behavior therapy in the
treatment of panic disorder. Behaviour Research and
Therapy 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.