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Compassionate Game Design: A Holistic Perspective for a Player-centric Game

Design Paradigm for Games4health

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International Journal on Advances in Intelligent Systems, vol 13 no 1 & 2, year 2020, http://www.iariajournals.org/intelligent_systems/

Compassionate Game Design: A Holistic Perspective for a Player-centric Game

Design Paradigm for Games4health

Aslihan Tece Bayrak

Dept. of Game Development
Media Design School, MDS
Auckland, New Zealand
[email protected]

Abstract—Despite the growing interest in using games for game is defined and shaped by its system-like properties that
positive health outcomes such as alleviating disease symptoms, are curated through game design. Therefore, guidance to unite
mental or physical therapies, or rehabilitation, finding suitable this understanding with game design would be beneficial for
games or developing custom games fit for purpose is challenging successful solutions.
for the researchers. Using commercial games for these purposes Even though industry practice advices and attempts for
pose various usability challenges and health and safety pitfalls. early involvement of players by methods such as playtesting,
When it comes to designing one, creating a compelling game is focus group activities, interviews, questionnaires and usability
already challenging. This article presents a novel theory called analysis, participative practices in game development are not
compassionate game design that aims to encourage development
in the same form or shape as such in product design and
of compassionate games with the help of a player-centric game
development mainly due to the creative nature of intellectual
design paradigm. The paradigm facilitates a closer exploration
for affordances and limitations of games for players with property. Lack of player-centered approaches to game design
(mental or physical) health conditions or with diverse physical in commercial contexts was also discussed by other
and cognitive abilities. The main contribution of the paradigm researchers [30][35][54]. In the hindsight, common industry
is its ability to promote a closer focus on player resources and practices and priorities for commercial game development
encourage a diverse inquiry towards creating games that are may not be relevant or efficient for developing games for
more compassionate. special purposes such as learning or health and rehabilitation.
Lack of a suitable game design methodology that explores
Keywords - game design; player-centric design; user-centered designing for these demographics seems to be a result of lack
design; accessibility; games for health; compassionate design. of engagement with design research within games studies
[21]. Therefore, creating player experiences for special
I. INTRODUCTION purposes that are embedded in entertainment can seem
The interest in game based interventions or game assisted overwhelmingly complex for a researcher who is not
treatments for greater health benefits has increased identifying as a game designer. Both for the use of commercial
significantly over the last decade with a visible change games and in order to develop new games, there is a need for
towards a more positive perception of games. Games for further design research to inform suitability and purpose of the
health research hopes to leverage the compelling nature of games for health outcomes [4][5][28]. A player-centered
games for positive health outcomes. For the games aiming to model that unfolds the layers of a game experience with
assist medical treatments or provide therapy or rehabilitation, respect to the player’s perspective can help a designer (or a
the target player group is special as they are very different than researcher-designer) cut through this complexity.
a healthy player demographic. Despite the increase in the This work presents a player centric design paradigm for
variation of player demographic playing all kinds of designing games for health and rehabilitation purposes. The
commercial games [63], the symptoms or the impacts of a paradigm is player-centric by prompting the designer to
disease such as (motor or non-motor symptoms) in Parkinson contemplate on player perceptions and player capacity. It
Disease (PD), or the effects of the conditions (such as mood encourages the designers to reinforce a closer relation across
or attention span in autism) are what makes a player the layers of the game experience while promoting a
demographic special. This means depending on the discussion to understand the relation between players’
complexity of conditions, the ability to perform in a conditions and the layers of the game. Therefore, it
commercial game is limited, and the chance of frustration due emphasizes compassion for the current state of the player in
to failures during the performance is high [4]. When the main terms of their disease (especially if they have a chronic
purpose for using a game is increasing adherence to the disease), mental and physical stamina, or their abilities in
therapy or treatment, the game needs to be engaging while order to foster development of suitable game elements for
also fulfilling its core purpose, i.e., therapy, rehabilitation, positive health benefits. This means game design is influenced
treatment, etc. [28]. Therefore, games that are designed for by a player model. In Merriam-Webster, compassion is
this purpose need to be favoring player’s conditions while also defined as [a] “sympathetic consciousness of others' distress
establishing motivation and engagement. This means, a clear together with a desire to alleviate it”. Thus, the model aims to
approach towards understanding the needs of the player and support creation of a compassionate game.
usability scope of the game is essential. Usability scope of the

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International Journal on Advances in Intelligent Systems, vol 13 no 1 & 2, year 2020, http://www.iariajournals.org/intelligent_systems/

To present the paradigm, its development and application, TABLE 1. FORMAL ELEMENTS OF GAMES AND THEIR DESCRIPTION;
REPHRASED FROM GAME DESIGN WORKSHOP BY FULLERTON [19].
the paper is composed of the following sections. Section II
presents the motivation and background work to explain why
Formal Description Supporting questions
this paradigm is necessary and the plateau of literature to elements of
ground the work. Section III discusses the methodology. games
Section IV explains what compassionate design is and its players The main agents of the How many players, what
challenges. Section V presents the player-centric design game; define interrelations are their roles, and how do
among players, the effects they interact with one
model with its layers and main elements while Section VI
of rules on players, etc. another?
presents a discussion and conclusion.
procedures Methods of play and What exactly the players
actions towards achieving do, how do they do that?
II. MOTIVATION AND BACKGROUND the game objectives
This design paradigm emerged during a research through resources In-game assets that can be What can I afford? How is
design activity, and further developed into its current form used to accomplish goals; a resource useful to the
they are a part of in-game player? When and how
with a synthesis of existing game design approaches and user economy; they must have the player can access/lose
experience research. A scoping review for player-centric (or utility and scarcity. resources?
player-centered) methods for game design revealed little in objectives Represent the purpose of What are the players
terms of an established methodology, techniques or model the player within the rules trying to achieve? What
while the notion of player-centered design is commonly of the game. kind of impact do the
mentioned to be favored as user-centered equivalent of user objectives have on the
game?
experience design. Current game design methodologies are rules Define game objects, What is the player
unhelpful to contemplate how to facilitate usability at the actions that are allowed and allowed to do? How are
game level, how each design decision impacts the player’s restricted; rules govern the the rules presented and
ability to play, and what to focus on during a design activity system. enforced?
involving players with health issues [35]. Treadaway et al. conflict Emerges from the What is the challenge?
[57] initiated a discussion on compassionate design for oscillation between goals What makes it
and rules (accomplishing hard/challenging to
dementia care and developed guidelines on the use of the goals within the given accomplish the goals?
compassion in activities of design for wellbeing. As much as rules is a challenge).
these guidelines bring important concepts to the spotlight, i.e., boundaries Define the physical and What are some physical
dignity and personhood, application of these in game design virtual play-space by limitations that define the
can be more effective if adopted by a player-centric thinking. separating game elements play space? What are
from anything that does not some conceptual
Towards synthesizing a player-centric design model for health belong to the game. limitations?
purposes, this section presents the state of the art on game outcome The result of the How does the game end?
design, player-centric design, players, player experience, and activity/session/game; this How does the player
games for health. The last subsection presents a case analysis must be visible and progress/advance?
to unite the background work towards strengthening the measurable. Is the objective reached?
motivation.
However, the relation between those are rather loosely defined
A. On game design or are not presented in a form that would easily allow their use
Literature has a few well recognized, sometimes loosely by un-trained game designers. Refraining from a detailed
defined, frameworks for game design and analysis. These are discussion on the set of formal elements, both the elemental
Schell’s elemental tetrad [20], Fullerton’s Formal-Dramatic- tetrad and the MDA framework present a high-level model
Dynamic (FDD) elements [19], Adams’ interaction model [9] based on visibility of the layers or different perspective
and mechanics-dynamics-aesthetics (MDA) [48]. All of these holders. Elemental tetrad and derivatives of this model [36]
agree to see games as systems that resemble the characteristics show a four-way relationship between mechanics, aesthetics,
of a closed system with the elements enclosed, their story and technology drawing attention to how visible these
properties, and relations between those elements [13][66]. are from outside the system. Even though this four-way
Among these, Fullerton’s formal elements are a core set of relationship is helpful for game analysis, it is too loosely
elements granular enough to allow a micro-level thinking for defined to be helpful as a game design approach. On the other
the design or analysis of a game [19]. Formal elements allow hand, MDA presents two separate viewpoints; one from
studying the game grammar by dissecting a game into its designers’ perspective, the other from players’. This makes
smallest building blocks. These are listed in Table 1. with a MDA a useful model to discuss different perspectives even
brief explanation on how they relate to game grammar. Notice though it is not helpful for the design process. For a game
that all formal elements are somewhat interrelated in their designer, mechanics are designed to give rise to dynamics, and
definition, role and use in game design. hence aesthetics are conveyed as a result of these dynamics.
In Fullerton’s FDD model [19], dramatic elements bring Therefore, they see mechanics, dynamic and aesthetics in this
meaning to the formal elements and establish context while given order. Here, aesthetics represents all emotional aspects
dynamic elements emerge when formal elements are put into that stem from the game. Conversely, player’s perception
motion. follows an inverse order: aesthetics-dynamics-mechanics. It is
framed with their perception of the aesthetics; therefore, their

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International Journal on Advances in Intelligent Systems, vol 13 no 1 & 2, year 2020, http://www.iariajournals.org/intelligent_systems/

viewpoint is always under the influence of their perception of interfaces [9]. Although this could be seen as a much clearer
the aesthetics. As much as elemental tetrad and MDA are approach that allows the use of existing HCI research for
helpful for contemplation on perspectives, they do not games, it creates further ambiguity on the potential needs of
facilitate a closer investigation towards dismantling a games on a visual and contextual level.
complete game experience into its thinner slices, explaining When game design literature is scanned for the role of
influences for experience design or designing a game for player in game design, it becomes apparent that player-centric
special purposes and/or special demographics such as people game design is not as common, but involvement of players in
with chronic health issues. Such granularity is missing and design process such as in participatory design is even less
would be very helpful for designing compassionate games that considered or troublesome [30][54]. A more often seen
would keep emphasis on the capabilities of the player. application of player-centric design is with early playtests and
Almeida and Silva [41] reviewed a collection of game the use of player personas rather than participatory design
design methods and tools (as per 2013) drawing attention to sessions as seen in product design or service design. As much
the use of visual languages and design modelling despite as iterative design practice is praised, most of the time studios
favored varyingly across industry and academic fields. They prefer to involve as few people as possible and as late as
argue that the immaturity of design research in game design possible due to secretive nature of creative production.
field prevents the adoption of these by researchers or industry. Sometimes an audience model is created to enable intellectual
Moreover, they note that the game design methods and tools assumptions for players’ needs assuming that designers have
under review lack representation of the player perspective, a decent understanding of what players wants and needs. This
especially for aesthetic components. Indeed, these approaches notion has been strongly criticized for neglecting the real
seem to mostly favor the game over the player, therefore persona of the player and reducing them to simple
lacking methods to draw attention to the player and facilitate unimportant actors disconnected from a larger socio-cultural
compassionate design. For this, a visual game design model context. Sotamaa suggests designers to focus on what they are
can be helpful for communication across researchers, good at while acknowledging the players as the specialists of
designers and other members of the development team while their own “everyday gaming” [35].
developing compassionate games. On the other hand, player involvement in context of
player-centeredness can also be considered continuous rather
B. Player-centric Design than finalized by the end of production period of a game.
It is commonly thought that the player-centric design is an Player modelling [27] and automatic/dynamic difficulty
extension of the user-centered design. On one hand, one can adjustment based on biosensors [53] are some methods to
argue that game design is inherently player-centric since it create more player focus during gameplay. Industry practice
always questions what the player is doing, what they are ackowledges the use of personas rather than focus groups [66]
allowed to do, their objectives, rewards, the consequences for since the involvement of individual tastes of potential players
the player, and how the player is supposed to feel during the may be noisy rather than useful for the designer even though
gameplay experience. Therefore, it would be unfair to suggest persona development or the personas themselves are rarely
that game design is not player-centric. On the other hand, shared by the game designers within the industry [44].
game design practice is a creative endeavor, meaning that it Inspired from Norman’s emotional design [12], Baharom
may carry a separate authorial intent due to its creative nature. et al. [33] suggest a conceptual framework that offers a
In the virtual boundary of play-space, the game world is valuable discussion about the relation between emotion,
governed by the rules and dressed in the metaphors of the perception, reason and structural elements of games. The
game. Besides, game design practice could also be perceived framework is encouraging for discussions on the cognitive,
as play-centric, putting emphasis on gameplay over other psychomotor and affective dimensions of games by placing
elements of the game. Therefore, rather than the habits, player-centric design in the center although interrelations
requests or expectations of the player, the nature of play and between these dimensions remain unclear. Hodent also argues
how it manifests itself may take precedence. In response to all that user experience (UX) should not be separated from the
these arguments, player-centric design is centered with design cycle as it is the glue that ensures intended experience
empathy to the player and aims to provide a positive and players’ perceptions work together to create an enjoyable
experience to the player despite contradictions with creative gameplay experience [56].
pursuit [9]. Therefore, player-centric design puts the player
before the creator. C. Unpacking Play and Players
Charles et al. also [27] acknowledge that most of the The concept of play and why people play have been a hot
player-centered approaches to game design rely on the topic for decades in social and cultural studies, psychology,
research on human factors and are adopted from user-centered and philosophy. Sutton-Smith argued for the cultural
approaches. Although these are useful for addressing usability significance of play stating that it takes many forms
issues at an application level, the additional qualities of games throughout the life of each individual [65], and Suits argued
as a media (such as the level of challenge, player skills and that games are central to human existence and that “everyone
gameplay, etc.) are not addressed. Adams presented another alive was really a grasshopper in disguise” [64]. Game studies
model that is based on the interaction between the player and as a relatively young research field also inherits this question,
the game, yet does not encourage explorations on sensory and further asks why people enjoy playing a game more than
complexity of games more than perceiving them as user another, what it is that people find in the activity of gameplay,

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International Journal on Advances in Intelligent Systems, vol 13 no 1 & 2, year 2020, http://www.iariajournals.org/intelligent_systems/

what motivates them for this activity, how this enjoyment is experience higher levels of satisfaction, and potentially
governed, how it can be shaped, etc. continue playing the game.
1) Aesthetics of play: Aesthetics, as adopted from MDA 4) Player personalities and preferences: The idea of
framework by [48], represents emotional aspects player types and that some features are favoured by some
communicated by the game. Previous section on game design types of players were first mentioned with the first Multi User
already mentioned that emotions emerge via the dynamics of Dungeon (MUD) [47]. Player types (sometimes referred as
the game experience, and mechanics of a game serve for the Bartle’s player types)—killers, achievers, socializers, and
aesthetic goals. The aesthetics mentioned by [48] are explorers were representing players’ interest in MUDs.
(broadly) sensation, fantasy, challenge, narrative, fellowship, Killers are interested in features that allow them to act on
discovery, expression, and submission. On the other hand, other players such as combat and direct interaction; achievers
Lazzaro argues that we play because it is fun despite the are interested in features that resolve with tangible
ambiguity in the definition of “fun”. She suggested the Four acknowledgement of success such as badges, unique items,
Keys to Fun method to explain the phenomena of “fun” [49]. etc.; socializers are interested in features that encourage
In 4Keys2Fun, fiero (hard fun), curiosity (easy fun), playing with other players, collaboration and social
excitement (serious fun), and amusement (people fun) are interaction; explorers are interested in adventure, discovering
chosen as four core emotions. Lazzaro presents groups of and mostly acting on the world. This is later adopted by other
emotions as subset of these four and discusses how some designers and researchers and expanded upon [51][52], still
actions (towards creating the game features) can resolve into somewhat staying true to the first four types but developing
these emotions. For example, actions of collection, rhythm interim types to suit the variety of game experiences present
and repetition create emotions of excitement, focus and today.
relaxation. Therefore, they create “serious fun”. The As much as continuation of play is of interest, it is argued
suggestion is building a play experience to evoke more than that there is a taste factor involved in a player’s initial choice
one emotion to prevent stagnation. to start playing [39]. Correlations between motivation and
2) Meaningful play: Salen and Zimmerman [13] state that taste may be possible although not supported by any research.
“the goal of successful game design is the creation of Regardless, VandenBerghe argues that taste factor can be
meaningful play.” Meaningful play emerges from the relation obtained by taste maps as presented in Engines of Play method
between a player’s action and the system outcome that is [39].
visible as immediate and long-term effect. If this relation is Engines of Play is a method suggested by VandenBerghe
not clearly visible to the player, players lose interest in the [40], initially at a game developers conference. It relies on the
gameplay. If the relation is discernable immediately and the Big Five psychological model (also known as Five Factor
result is integrated into the larger context of the game, the Model or OCEAN) and is suggested as a way to find out a
actions in the game become meaningful. With immediate correlation between game features and personality of players
feedback, the player receives a confirmation about their to enable a “more accurate empathy” towards different kinds
action; with long term effect, player sees that their choices of players. There is no empirical validation reported by the
matter and their actions carry meaning towards reaching their date of this writing; nonetheless, the idea is that people seek
in-game goals. Hence, meaningful play motivates the player out experiences that align with their personality traits. Five
experience. personality traits are mapped to five discrete domains
3) Motivation: Psychology studies on human behavior (OCEAN): openness, conscientiousness, extraversion,
consider that factors that activate and sustain behavior agreeableness, and neuroticism. This approach was further
towards a goal or that create propensity to learn and act are developed into taste maps to understand player motivations
motivational factors, and are either intrinsic or extrinsic in (domains of play) in relation to personality traits and game
nature. Intrinsic motivation comes from within such as features by VandenBerghe [40]. Later, in his blog he noted
enjoyment in the activity itself rather than for an external that the Engines of Play method was employed by another
reason whereas extrinsic motivation originates from an game studio to analyze their existing franchise as an early
external reward [45]. If extrinsic motivation is considered as exercise prior to adopting it in the future, and that the method
controlled motivation, through practice this can be was successful in terms of clarifying the reasons behind the
transformed into self-determined autonomous motivation success of the franchise and allowing all team members to
(hence intrinsic). Self Determination Theory (SDT) suggests effectively communicate intent and result at various stages of
that human motivation is based on three basic psychological development by using the stereotypes created with the taste
needs: competence, autonomy, and relatedness [37]. maps [55].
Competence refers to the universal will to perform better at Stereotypes mostly take the form of personas and inform
something; autonomy refers to the desire to be in control of the design process while creating contextual layer and
one’s own path; relatedness refers to the desire to connect aesthetics. In a post about player profiles for Magic: The
with other beings. Although SDT originates from the Gathering (Wizard of the Coast, 1993), Mark Rosewaters
psychology field, Player Experience Needs Satisfaction (head designer of Magic: The Gathering) explains that
(PENS) model [38] translates the dimensions of SDT into personas (he refers to them as psychographic profiles [44])
measurable domains for game development and analysis. allow him to isolate different personality traits and behaviors
According to PENS, when these three needs are fulfilled for so that what motivates a particular type of person to act in a
a player within the context of the game world, players certain way could become clear. He continues “[to] create an

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International Journal on Advances in Intelligent Systems, vol 13 no 1 & 2, year 2020, http://www.iariajournals.org/intelligent_systems/

emotional response, I had to understand what emotions I was than the interface itself; therefore, an isolated perspective that
trying to evoke”. Therefore, personas can be used to guide the only focuses on the experience based on interaction modality
design strategy with empathy so that suitable gameplay and the attributes of user interface would highly likely miss
features can be developed. the bigger picture for evaluating the experience of a game.
The bigger picture includes all facets of player experience
D. Unpacking Game Experience including but not limited to interaction modalities, user
Game experience research shows interest in understanding interface, audio-visual design, in-game challenges and
the emotional experience of a player so that a better and more objectives, player attention, engagement, immersion, etc. As
purposeful player experience can be created [62]. Towards Juul and Norton [46] point out, distinguishing the difficulty
this goal, user-centered design encourages the use of focus in interaction/interface and the difficulty of gameplay as a
groups, participatory design, usability testing, and usability challenge of the game is necessary to separate game usability
heuristics; however, the reception of these methods in games from that of production software. Since games are by nature
industry is mixed [59]. From a commercial angle, many inefficient and lusory, the line between difficulty in interface
studios seem to consider some of these methods less effective versus the challenge of a game could be rather blurry while a
or time/resource consuming. It is hard to argue against gameplay challenge can also be located at the interface.
business oriented decisions; however, this notion seems to be 3) Playability: Extending from usability research,
less effective when developing games for health and learning. playability and player-game interaction has been gaining
Commercially, a common thought in game development is some speed to explore practical applications for game
accepting that the product will not be appealing to all users usability challenges [16][26][34][62], and there is further
within the target demographic, therefore should be selectively work on playability and the complexity of player
designed for the most profitable subset demographic. involvement in player experience evaluation [25]. Sanchez et
Nonetheless, in the context of games for health and learning, al. [25] define playability as “a set of properties that describe
this notion can be challenged for the purpose of maximizing PX [Player eXperience]”, and add that playability measures
the reach of the product. Therefore, a closer look at the the effectiveness, efficiency, satisfaction and fun of
concepts of game experience is necessary. These are optimal performing to a specified performance as per the specific
experience, usability, playability, accessibility, and game feel. goals of the entertainment experience. Even though the same
1) Optimal experience: A balance between skill and attributes of usability are applicable to playability, their
challenge is often argued to create an optimal experience for meaning are different. Since the main goal of PX is
a person in any kind of performance; flow [50]. Challenge entertainment, Sanchez et al. collated seven attributes to
depends on the fine balance between an individual’s ability characterize playability: satisfaction, learnability,
to perform up to the standard of a given objective. When they effectiveness, immersion, motivation, emotion, and
do not have the competence to fulfil the demands of the socialisation. Among these, motivation and emotion are
activity, they feel anxiety. Flow theory explains that there are directly about the user and shaped by player preference. In
seven core components to flow. They are categorized under addition, motivation is also said to be “a key factor in
conditions and characteristics. Conditions (clear tasks, generating a positive experience for the player.
feedback, concentration, attainable goal) are the prerequisites 4) Accessibility: Despite the well-defined nature of
of flow while characteristics refer to the experience of the accessibility within user experience domain, accessibility
individual in the state of flow. They are control, diminished may differ for special demographics [33]. Accessibility of a
awareness of self, altered sense of time. According to game refers to the ability to enable the participation of people
Csikszentmihalyi, maintaining this balance is one of the most with disabilities to interact with the game and play without
critical prerequisites for flow, and it is important for both feeling any barriers during their interaction with the game or
motivation and learning [50]. In order to maintain during overcoming the challenges presented by the game.
engagement and promote flow, challenge should be matching Isbister states that “video games should be considered above
player growth in skill, tasks and goals should be made clear, all as complex IT systems, with which individuals wish to
feedback should be timely and readable, and distractions interact within the framework of a goal-directed activity”
should be minimized. [34]. In fact, the complexity of each differs depending on pre-
2) Usability: Usability in game development aligns with designed layers of gameplay experience, which may be open
common usability guidelines developed for human computer to emergence of more complex behaviours in some cases. On
interaction even though usability for games and game-like the other hand, accessibility seems to be simplified to
experiences encompass more than just the interface or the interaction modalities without much consideration on
interaction modalities. Nielsen and Norman group defines cognitive load, emotional demand or context related issues.
usability as ”a quality attribute that assesses how easy user There is no disagreement on the importance of a suitable
interfaces are to use” [6]. A usable interface should be easy interaction modality and a satisfying user experience, and that
for a user to become familiar with and competent in; to they are integral to the creation of engaging and enjoyable
achieve their objective; to discover previously less known game experiences. Furthermore, it is essential for a player to
attributes when need arises; to recover from an error; and to be able to see past the interaction modalities while playing a
recall how to use the interface on subsequent visits. As much game so that they could fully engage with the activities and
as these can be valid for a game interface, it is necessary to events in the game, hence be in the flow of the game. Juul
note here that player experience (game experience) is larger

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International Journal on Advances in Intelligent Systems, vol 13 no 1 & 2, year 2020, http://www.iariajournals.org/intelligent_systems/

emphasizes that challenge of the gameplay should never be studies. Both for the use of existing commercial games and
mixed with interface difficulty [46]. with the purpose of developing custom games, there is a need
5) Game feel: Game feel, in Swink’s definition, is “the for further design research to ensure suitability and
tactile, kinesthetic sense of manipulating a virtual object” accessibility of games for special demographics [4][5].
[10, pg.xiii], and it is essential to the game experience. Three Potential recipients of game-based rehabilitation include a
building block of game feel—real-time control, simulated variety of age groups across a variety of diseases such as
space, and polish, shapes the game feel towards resolving into cerebral palsy, ADHD, autism, post-stroke, Parkinson’s and
five common experiences. They are (as taken from [10, parkinsonism, age-related deterioration, etc. Development
pg.10]): initiatives for games for health in each of these seem to be
• The aesthetic sensation of control; discrete and isolated. Even though the requirements of each
• The pleasure of learning; and every rehabilitation and limitations of each and every
• Practicing and mastering a skill; target user group are different, it is not unrealistic to expect a
• Extension of the senses; common design strategy or a framework that can
• Extension of identity; accommodate common methods to develop games that
• Interaction with a unique physical reality within the augment rehabilitation during the treatment of these diseases.
game. Within games for health context, a set of guidelines was
The pleasure of the game experience mostly maps to a collated to inform developers on the special constraints for
combination of those. For example, with driving games, it is their design [11][14][17][18] while also pointing out the lack
more about the aesthetic sensation of control; yet, while of further development in the game design discipline. Game
driving in an obstacle course, it is more about practicing and design in its practice is agile and opportunistic, yet the design
mastering a skill. When the car is damaged, and the player practice itself is under-researched. A study by Isbister and
screams at that moment, it is about extension of the senses and Mueller on variety of interaction modalities especially in the
identity. This is also how game feel connects to SDT. As a field of movement based games is one of the few that
player gets better at performing in the game, their competence evaluates conditions of interaction and suggests strategies for
increases. As their competence increases, they will feel and a more successful design of movement-based systems, mainly
demand more autonomy for their actions. The combination of games [17]. The guidelines provide insights for the design of
balanced competence and autonomy (resembling optimal interaction modalities, necessary feedback compatible with
experience) makes them motivated. As they feel motivated the interaction device and activity, extends from self-
and focused on the experience, they will feel connected to expression, challenge and fun. Among the few studies that
their avatar or their car that they are driving; hence, their attempt to develop games for PD patients, Assad et al.
avatar becomes a part of their identity. previously suggested design principles for designing games
for PD, particularly for motion based games for rehabilitation
E. Games for Health and Rehabilitation purposes [11]. Although informative, the principles are
Over the years, literature on games for health has grown prescriptive for a specific type of game (such as arm extension
with both the use of commercial games and the development based exercise features or balance features) rather than
of custom made games for health benefits including but not allowing a wider applicability supported with a clear
limited to improved balance and gait, muscle strength, reach, methodology for game design. Moreover, while each item in
etc. [2]-[5]. Games are considered as a solution to non- the guideline can be affecting various areas in the game, the
adherence to therapy, the lack of motivation for therapy and/or interconnected nature of the game experience as per these
rehabilitation, the service and delivery costs of therapy such affects is hard to perceive. Therefore, a model such as the one
as unbalanced patient-therapist ratio, reach to and distribution presented in this paper could have been useful to guide the
of services, lack of accuracy in tracking progress, etc. There designer towards realising these relations. For example,
are convincing arguments [28] about using commercial games fostering wider and fluent movement is advised, but input
for physical therapy since they are already products that are modality is not discussed probably because the guidelines are
commercially developed to create and maintain engagement; aimed for movement based games. Gerling et al.’s “extended
however, clear contributions on re-appropriation of existing model” (seem to be extended from Fullerton’s formal
games for specific purposes and maturity of guidelines to elements [19]) presents a useful basis for designing for older
adapt those for people with chronic diseases are limited. adults [18]; however, the analysis lacks a wider perspective on
Similarly, researchers have mostly adopted or applied existing the interplay between the elements of the model in relation to
game design models [9][19], some extended from existing a player-centric focus. As a game design paradigm, such
models [18][31], or developed on an ad-hoc basis in order to perspective would encourage an exploration of player’s
create a suitable product without much exploration on the perspective in this context especially for the needs/issues of
design practice [4][5][14][15]. Lack of a design methodology special demographics with health issues. Nevertheless, the
to facilitate design exploration for a selected demographic notes on the player’s abilities (both cognitive and motor
with unusual limitations, such as motor, cognitive or mental abilities, such as attention span, short-term memory, repetitive
difficulties that may be developed due to a chronic disease, input, etc.) to be considered as resources resonates with the
seems to be a result of limited design research within games perspective of compassionate game design concept presented
research [21]. This means, learnings and observations from here. In line with the previous discussion here, Burke et al.
these studies are fragmented and hard to reconcile for further [29] suggested three principles to game design for health and

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rehabilitation: meaningful play, handling failure and setting a 3) Cognitive impairments: Cognitive impairments that
suitable level of challenge, and applied these to the are commonly seen with PD are learning and retaining
development of games for the rehabilitation of stroke patients. information (working memory), concentration and attention,
Despite limited reflection on the development process or the and executive functions. Executive functions are a set of
design iterations, the note on adaptive aspects of the games
inter-related cognitive processes that are essential for goal-
and that they were well-received by the players is valuable.
directed behaviours [24]. Even though they are heavily
F. Case analysis: On Design Challenges for Players with related to cognitive domains, motor skills and connection
Impairments due to Parkinson Disease between cognitive and motor skills are the main reason why
In light of state of the art presented above, this subsection they are absolutely necessary for activities of daily living
presents a case analysis to unite the background work towards [24][23]. In order to preserve gait, a person needs to evaluate
strengthening the motivation. In this example, the case their surroundings, strategically decide a path of movement,
analysis looks into the difficulties that people with PD may be shift their weight and meanwhile check their balance. If they
facing in their daily life. In the context of compassionate come across an obstacle, they should be able to stop
design, these difficulties help addressing the design executing their plan and rework a new plan similar to the
challenges. A similar analysis would be useful, in fact
correction cycle mentioned before. This means all six
necessary, while attempting to design for a special
demographic. Later, in the presentation of the paradigm, the executive functions are actively used during a simple walking
notes from this analysis is used to show how challenges are task: attention, inhibition, planning, reasoning, shifting
addressed within the holistic nature of the paradigm. (flexibility), and working memory. Gait disorders share
Research shows that quality of life for PD patients drops similar issues originating from deficiencies in executive
over time meaning that activities of daily living, such as functions and also observed among older adults. This means
dressing, grooming, bathing, self-feeding and functional impairments in executive functions also develop among older
mobility are jeopardized as disease develops [23]. Even at adults, perhaps milder than PD. In addition to a previously
earlier stages various disturbances and impairments limit the identified need for task creation frameworks to facilitate
ability of the users while performing tasks that are considered purposeful use of games for special demographics [4], it has
simple; rendering many games inaccessible for this player
become appearant that there is a need for a design paradigm
base. The disturbances and impairments that are commonly
observed across PD patients are sensory sensitivities, motor that draws attention to the abilities and limitations of the
impairments, cognitive impairments and emotional players, thereby clearly mapping the position of the player in
sensitivities. Many of these impairments, especially in early relation to the game experience. Therefore, the player-centric
stages of PD, show close similarities to age related changes design model is developed to support and inform designing
that are commonly observed among older adults or other games for rehabilitative and preventative therapies for PD.
health related situations, such as stroke patients [14].
1) Sensory sensitivities: Sensory difficulties include not III. METHOD
only hearing or vision problems as mostly seen with elders The method of this study is design science research (DSR)
[18], but also sensitivities for sensory overload due to visual while the presented work aligns closer with the idea of
and sound stimuli. Occupational therapy for PD advise developing a nascent theory through the means of DSR [42].
reducing visual stimuli by reducing confusing patterns Despite the emergence of new frameworks or design
(striped-checker), strong colours and hues, and simplifying principles towards facilitating purposeful use of games for
serious means such as creating positive change, alleviating
the load by preventing contrasting visuals and clutter [22].
disease symptoms, chronic disease rehabilitation, etc. [28],
Visio-spatial disturbances and strong contrasts cause freezing there is a clear fragmentation in the design field, separating
while clutter overloads cognitive processes with a need of other more flourished design fields and game design. The
strategising and replanning. There are no specific sensitivities compassionate design philosophy and the player-centric game
reported about audio; however, the use of metronome and design paradigm are developed through grounding strategies
inducing percievable rhythm into daily life are presented to [42], and the synthesis draws from human computer
be useful to enhance motor abilities [22]. interaction, user-centered design practices, and game design.
2) Motor impairments: Main motor impairments As per the activities of DSR compiled by [43], the activities
observed in PD are trembling fingers and hands (tremor), of this research are below.
rigidity, slowness in movement (bradykinesia), and gait • Activity 1: Problem identification and motivation is
problems [22]. Subtle slowness in movement, postural discussed in Motivation and Background section
(Section II) while conceptual grounding is also
change and gait problems are also seen in elders even though
presented. Existing approaches for the intersection of
the scale of these differ from PD. Trembling fingers and game development, user-centered design and the state
hands, especially depending on the scale of movement can of the art for design approaches for games for health
make it very hard to use an input device or perform button are presented. Core issues of research projects
presses while the slowness in movement can increase the utilizing games for therapy/rehabilitation of special
response time. demographics including chronic diseases and elders

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are (1) researchers’ potential lack of knowledge and IV. COMPASSIONATE GAME DESIGN
understanding for game design and development What is meant with compassionate game may seem fluffy
towards creating a compelling game experience or and idealistic. However, the idea of a compassionate game
selecting a suitable game, (2) the complexity of a originates from the comfortable and embracing feeling of
game experience that would fulfill the requirements compassion. Compassion has been actively practiced within
of a therapy (or rehabilitation), and (3) the ability to the context of healthcare and made its way into public
identify the necessities and expectations of the chosen healthcare policies despite the ambiguity of its application as
demographic within the context of game design. compassionate care [61]. In healthcare context, the meaning
Hence, the conceptual grounding not only provides a of compassion sometimes gets mixed with dignity, identity,
motivation for the problem but also synthesizes and self-worth. Regardless, it is suggested that caring
theory from the material sources in order to build conversations and building relationships with the patients can
grounding material for the suggested paradigm. help to effectively practice compassionate care [61]. If we are
• Activity 2: In relation to the problems identified in the considering games as platforms to deliver or support
previous section, objectives for a solution are healthcare, we need to start practicing ways of integrating
discussed in the Compassionate Game Design section compassion into game design.
(Section IV). The core objective is drawing attention A compassionate game would tolerate the failures of a
to three areas about the player: (1) player-game player with kindness rather than confrontation so that the
relation, (2) player resources, (3) player perception failures are perceived as opportunities of development rather
and game content. The objectives of the than unsuccessful attempts; therefore, the remaining feeling is
compassionate design are explained starting from not frustration. A compassionate game would allow for a
these three areas while value grounding for these are grace time that suits a player’s capabilities rather than
also enclosed. Following from the core problems confronting the player with a challenge that they cannot
identified with the activity 1, the activity 2 reinforces improve upon; therefore, the remaining feeling is not a decline
the development of the compassionate game design in self-esteem. Compassionate games would not compete with
concept. Hence, a leading philosophy for the design the player on a layer that the players cannot improve; they
paradigm is developed via an inquiry on purpose and rather encourage the player for participation by providing a
action. harmonious and suggestive environment of support and care.
• Activity 3: In response to the objectives identified Therefore, they strive for accessibility, inclusivity, care,
during activity 2, the player-centric design paradigm tolerance and adaptation. Compassion in this sense may seem
is developed to present an easy to apply model for to conflict with the notion of challenge and conflict in game
development and selection of games for a special design. On the contrary, it is about finding the right area in the
purpose. The paradigm presents a clear account for game design where challenge should be planted so that it is
the layers of a game experience, how these layers are possible for the players to fairly overcome the challenge rather
interconnected, and the role of the player in relation than facing an unsolvable/impassable problem due to their
to these. The details of the concepts across the model, limitations; thus, feel incompetent. Therefore, compassion
their nature and their relations are explained in the does not suggest removing the challenge but planting it in an
Section V. area where player progression is not limited by the disease.
• Activity 4: The purpose of the paradigm is enabling Hence, it is about care and tolerance with an understanding of
the development or selection of a game fit for what a player is going through so that their competence
purpose. This activity is dispersed across the develops.
explanation of the model in Section V. A detailed Applying compassionate game design means seeking
discussion for the application of the model as per the further inquiry in the design process in relation to three areas
holistic capacity of the paradigm is presented. The about the player: (1) player-game relation (at a one-to-one
application of the model, design examples and level), (2) player resources (skills and abilities), (3) player
validation fall out of the scope of this paper and are perception and game content (what is going on in player’s
planned for future work. mind versus what the game is offering). By doing so, the
player model, as the central element of compassionate game
The work stands as a theory building DRS activity to design will be integrated into the process of developing a
create synthesis across diverse fields while providing an easy game that is compassionate towards its players. The following
to follow perspective for researchers, who may be new to subsections present the compassionate design concept as per
games for health or who may have limited knowledge about these three areas while the last subsection discusses the
game design. The artefacts of the activities are the challenges of compassionate design.
compassionate game design concept (presented in Section IV)
and the player-centric game design paradigm (presented in A. Player-game Relation: Interactivity
Section V). Strengths, limitations and future steps are Crawford [66] defines interactivity as “a cyclical process
discussed in the last section. in which two actors alternately listen, think, and speak. The
quality of interaction depends on the quality of each of the
subtasks (listening, thinking, and speaking).” This points to
the relational prospect of interactivity and its iterative nature.

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The micro level (the smallest interactive cycle, i.e., moment- The figure above (Fig. 1) presents the stages of the
to-moment) and the macro level interactions (a larger interaction between player and the game (action correction
trajectory of interactions) are intertwined to create a cycles from top to bottom):
meaningful player experience [13]. Within compassionate • (1) When it is player’s turn, what happens at player’s
design context, a compassionate game would show end: Player perceives the situation, it goes through
competence in listening more attentively, finesse in speaking their cognitive process, then player creates a motor
with care, and less complexity in the combination of response; meanwhile, the game waits.
interactions and interaction modalities. Therefore, the design • (2) When it is game’s turn after player initiates an
paradigm needs to draw attention to the flow of interaction. action, what happens at game’s end: Game receives
Citing from Sutton-Smith, Salen and Zimmermann [13] input, processes the information in its structural core
refer to game experience as a combination of five dimensions: (games as a closed formal system), then
visual scanning, auditory discriminations, motor responses, contextualizes the outcome with information layer,
concentration and perceptual patterns of learning. Players then feeds the information to the presentation layer
scan the entire scene based on the visual and auditory signs via relevant metaphors.
while concentrating on events and signals provided by the • (3) When game responds for player’s turn while
game. They perform actions based on the demands of the waiting for a reaction from the player, what happens
game and proceed whilst scanning for visual and auditory at game’s end while waiting for player’s reaction:
cues. This cycle continues as the player carries on playing the Game presents the current state of the game and waits
game. As they do so, players learn more about the patterns of for an input (response of the player); then receives the
play and improve their understanding of the game from input and passes it to its core to process as response
familiarity to higher expertise. At its core, the cycle of play is again. From the moment an input is received, the rest
an implicit micro game loop that stands on the perceptual of the cycle is the same as the second cycle. When the
understanding of the game world, the processing time of the game reaches to the second step here—waiting for
perceptions, and the response from the player. Norman response, this step is where the first action cycle takes
suggests that the ideal interaction cycle is present when no place.
psychological effort is necessary to use a system (bridge the Each of these interaction cycles requires well-tuned
gulf of execution) [58]. This resembles the correct game feel graceful delay for player action (the moments that the game
notion in which the performance of interaction with the receives input), and player perception (the moments that the
system becomes a compelling spatial presence [10]. game presents output). Intended player actions or player
Swink explains the interaction cycle as an action- reflexes should be considered to be potentially affected by
correction cycle where player perceives an interim goal their condition, so should player perception—as it includes
towards completing an action and slowly reaches their target, vision, hearing, and cognitive processing that may also be
except this happens so fast that we do not necessarily notice affected by their condition. This means response from the
the process [10]. The trouble arises for people with game should be perceivable by the player with longer and
neurodegenerative diseases. Due to motor or/and cognitive lingering feedback to support the moment-to-moment
impairments, a part or some parts of the action-correction gameplay within an action-correction cycle and ensure a
cycle show delays; therefore, the action becomes harder to continuity of perception. More about the response of the game
perform. When there is delay at system’s end, we see that as a and forms of the response are discussed as the paradigm
usability problem due to the lack of timely feedback. When explained in Section V (Subsection D).
delay happens at player’s end (Fig. 1), system needs to be
gracefully waiting and in fact supporting at times by B. Player Resources (Skills and Abilities): Game Difficulty,
additional supportive feedback. Since our main concern is Challenge and Accomplishment
reducing frustration and increasing compassion in our design, Starting questions for identifying the right challenge for a
we need to consider this cycle both for the player and the compassionate game experience goes through identifying the
game. areas impacted by a disease or condition. A thorough analysis
for the underpinnings of impairments, disease symptoms,
physical or emotional difficulties enhances the start of a
better-informed game design process. This is exemplified in
the case analysis presented before. Previous discussion on
formal elements (Section II.A) already mentioned the holistic
nature of these elements. While the conflict between the in-
game game objectives and the rules form the challenges in the
game, difficulty sits in a sliding scale based on what kind of
skills are necessary and the complexity of the procedure to
perform in-game actions. Player skills, abilities, and capacity
shape the player performance, therefore player experience.
Figure 1. Interaction between player and the game when an action is This means the paradigm needs to draw attention to these for
initiated by a player or a game a true player-centered approach.

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Skill, as per the definition we use from the dictionary1, is remind without drawing attention to the reality that they did
“dexterity or coordination especially in the execution of not pay attention in the frst place.
learned physical tasks”; ability 2 is “the quality or state of 3) Emotional resources: In playability context, Sanchez
being able”; and a resource loosely refers to the capacity. In et al. [25] refer to the emotion as players’ involuntary
this context, the players suffering from a condition such as response. In the context of compassionate game design,
motor impairments may have the skill (originally) to perform emotional resources refer to the capacity in perseverance
fine motor tasks such as buttoning a shirt; however, their while feeling those emotions evoked by the game. It is less
ability may not be allowing to do so any more. This is most of likely that a player would find it hard to deal with too much
the time true for all patients as they go through different stages fun; however, it is more likely that they will have a limit for
of a chronic disease [60]. For diseases such as PD, frustration before they give up playing the game. Thus, the
Alzheimer’s, Dementia, etc., cognitive skills, motor skills, emotional resources are resilience, self-esteem, self-efficacy,
emotional and physical stamina deplete over time as they trust, etc. The capacity of the emotional resources can be
progress. influenced if not directly affected by a disease or a condition.
Player resources pose a larger problem depending on The response of a game at moments of success and failure
patient demographics. For example, Parkinson’s patients may drain or refill this resource.
develop cognitive impairments such as working-memory 4) Physical resources: These refer to the capacity in
issues, or reduced flexibility and inhibition, which may hinder physical performance including the ability to perform
their strategic planning ability. Even when they are able to throughout the gameplay session (endurance), ability in
perform a level of strategic planning, how fast they get tired combined tasks such as movement and button press
in the process of re-strategizing restricts their capacity in this (dexterity), speed, muscular strength, power, etc. This may
task, therefore their resource for strategic planning. They also sometimes overlap with motor resources especially when
develop motor-skill impairments such as precision control, precision and reach are required as in interactive dexterity by
bradykinesia, freezing, etc. As disease develops, the scale of Sanchez et al. [25].
these hindrances grows demanding more support and Overall, failing forward and a positive reinforcement
compassion from the system. Since these impairments limit throughout the challenge as per the previous discussions on
their cognitive and motor ability to perform precise, repetitive motivation and optimal experience, should be the driving
or complex tasks, this means their cognitive and motor force of a compassionate game. According to dopaminergic
resources to perform in this system is limited. In addition, their studies [28], it is noted that uncertainty of result (win or lose)
physical resources such as endurance, agility and stamina are and almost succeeding or narrowly avoiding failure increase
limited along with their emotional resources such as not only motivation but also dopamine release.
resilience, self-efficacy, and self-esteem. Hence, it is
important to identify the resource intensity of the skills (type C. Player Perception and Game Content: Motivations and
and scale of resources—motor, cognitive, emotional, Reservations
physical) necessary to perform to a level of completion. Playing a game is rewarding; it rewards the player with an
1) Motor resources: These refer to the capacity in experience of “fun” as long as they wanted to play it. Swink
performing activities with fine and/or motor skills such as suggests a challenge for a game designer is to create a game
quick-response, timed-response, precision, repetition, reach, mechanic that is worth learning for players [10]. In fact, the
etc. If the ability of a player is already restricted in any of difficulty of learning a procedure for gameplay only becomes
these domains, interaction modality needs to accommodate worthwhile by the return of that action and how integral that
the restriction. For example, people with tremor may not be action for the continuum of gameplay. Therefore, rewards of
able to use a control scheme that requires timed-response and mastery, how difficulty of a procedure scales for the variety
precision simultaneously. What is and is not achievable by of individuals with diverse skills and abilities, and the relation
the player needs to be identified in the process. of the mechanic to the contextual layer of the game (its art,
2) Cognitive resources: These refer to the capacity in theme and story) shapes the motivation. Meanwhile, pre-
performing activities that demand cognitive abilities such as judgement, previous experience or fear shapes reservations. If
remembering a number of items for a certain amount of time the reservation grows larger than what motivations has to
(working memory, short-term and long-term memory), offer, it causes non-adherence. For a compassionate game, the
attention (selective attention, sustaining and retargetting challenge is creating pathways to overcome the reservations.
attention), anticipation (pattern recognition and prediction), This goes through positively changing the player perceptions.
decision making, problem solving, planning (sequencing, Games have the unique ability to invite people in and persuade
prioritization, reordering), etc. People with conditions that them for participation. Their ability to shape perception and
affect cognitive resources, executive functions are also fight reservations of the participants should be explored
affected [24]; hence, quality of life is under threat. For further towards creating compassionate games.
example, people with attention deficit hyperactivivity
D. On Challenges of Compasionate Game Design
disorder (ADHD) will find it hard to sustain their attention;
therefore, a game designed for this target demographic needs Within the context of compassionate game design, a game
to reclaim their attention repetitively and be ready to gently that is not able to accommodate a player’s health or learning

1 2
https://www.merriam-webster.com/dictionary/skill https://www.merriam-webster.com/dictionary/ability

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related difficulties is considered to be impaired. Therefore, the art assets and poor choice of color palette would also reduce
main challenge of compassionate game design is removing the the quality of game experience. For a user interface (UI),
impairment of the game so that it is playable by special chosen color palette, negative space, density/scarcity of visual
demographics. This starts with identifying areas that players elements, placement and alignment of UI elements such as
are struggling due to their conditions. As a starting point, these button, text boxes etc., consistency of all UI elements in and
areas can be categorized in three domains: sensory challenges, across the pages including font, size and color, and the feeling
physical challenges and cognitive challenges. For example, a and readability of transitions are extremely important. All
core challenge of game design for special demographics with these elements come together to create the right feeling for the
health issues is the restrictions on the physical and cognitive interface with its content and suitability to the context. Similar
abilities of the player group. When this merges with the but more intense, contextual content of games requires far
perceptions of the players about the nature of the activities, it more depth compared to a user interface. The player
becomes hard to create motivation to play the game. perceptions of the game world not only stem from the
Therefore, it is important to notice that when players are not narrative elements that are telling a story of the game world
able to fulfil the expectations of the moment-to-moment but also the familiarity of the player with the game and game
gameplay simply because it is not possible due to their current world. Therefore, the player needs a high processing power in
condition, they will lose interest in the game as the game is order to evaluate all the information they could gather from
only another reminder of their inability; hence, the experience the game in real time while playing the game. Thus, complex
is not enjoyable. Then, the challenge is introducing tolerance visual stimuli may become paralyzing if the system does not
and support for these moments of need. show enough compassion when a player’s impairment is
According to Swink [10], any delay that breaks the getting in the way of their play activity. Without a model that
continuity of an experience creates poor game feel. Therefore, helps breaking down areas that demand processing power and
a game needs to be responsive for the player inputs. Similarly, areas to hide delay, it is uneasy to contemplate on how this
any player action in response to the events presented by the need could be resolved without frustration.
game needs to be timely; otherwise, deemed unsuccessful by
the game. Hence, the game acknowledges successful behavior V. A HOLISTIC MODEL FOR PLAYER-CENTRIC GAME
and rewards it while also clearly communicating the DESIGN
consequences upon failure. From a purely game design point The model seen in Fig. 2 attempts to draw attention to the
of view, facing consequences helps to reinforce meaning in identified core areas of compassionate design as per the
choices. However, from a player-centric design point of view, discussion in Section IV. It aims to encourage a designer to
especially for players with motor and/or cognitive take a player’s perspective in relation to the formal structure
impairments as in Parkinson’s or stroke patients, how much of games and aims to enable a deeper discussion on game
time should be evaluated as the time-frame for “timely design challenges for special demographics. In doing so, the
response” is unclear. The procedures of the game should be purpose is presenting a holistic map laying down the building
forgiving with a suitable error margin and compensating for blocks of the compassionate game design concept. This
delays as motor-cognitive processes in player’s mind may concept becomes readable with a game model and a player
take longer than an ordinary player. This may mean shifting model that interacts with one another. With a player-centric
the challenge to another aspect of game rather than using focus, the model (Fig. 2) is extended from [1], and combines
input-timeliness, input-combinations, or input-related layers of player experience—as inspired from Garret on the
challenges as a central element of core gameplay. Especially planes of user experience [7][8]—with Adam’s game design
for anxiety prone demographics, removing time-constraint model [9] and Fullerton’s formal elements [19]. In addition,
related design elements such as time-trials (obvious time Mayra’s [67] core and shell dialectic informed the work for
constraint), falling platforms (hidden time constraint), explaining the relation between formal elements of a game
traversal challenges (time constraint imposed by combination and a game’s context. In a simplistic fashion, the dialectic
of other elements such as enemies, moving platforms, etc.) all captures the actors of player experience to start a conversation
together could even be a more suitable approach. In about their relation even though it lacks details to explain the
consideration of mental barriers, such compassion would potential elements of player experience or player’s role in this
reduce anxiety and stress, while replacing those with dialectic.
confidence, self-assurance and trust. The rationale for compassionate design is discussed in the
Game accessibility requests compassion from the system previous section including a perspective for potential
to bridge the gap between the player and the game in order to challenges it may entail. Here, player-centric game design
reduce the impact of impairment. For example, similar to how model is explained with its layers.
a poor visual design of an interface would reduce the usability
significantly, a poorly developed game world with low quality

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12

Figure 2. The player-centric game design model aims to encourage the development of compassionate games (extended from [1]). Therefore, it favours a
player model by bringing transparency to the capabilities of the player and helps a designer to perceive the system from players’ point of view.

With this model, a designer (i.e., researcher as a designer)

can map the systematic flow of player experience and the B. Player Model
mechanisms carried out in the game without losing focus on Player model is composed of player perception and player
the player end of the game world. When the interaction cycle resources. It considers the player perception as a combination
starts with a presentation of a game scene to the player, player of motivations, reservations and a mental model through
observes it through their perception. As they act via pressing which players engage with the game world. Swink refers the
the buttons on the controller, moving the joystick or somewhat player perception as “perceptual field” [10] that is a
invoking the input layer as per the interaction modality combination of all previous experience including ideas,
available to them, the game receives this input and carries it thoughts, memories, etc. From a player’s point of view, game
to the structural core of the game to be resolved as per the is only the interface since they do not need to know about (or
predefined rules (as per the formal elements of the game). perhaps are not interested in) any inner workings of the system
When this is resolved, the response will be dressed up by the (Fig. 3).
contextual layer (in order to fit with the theme and style of the
game) and shaped into the form of necessary information as
per the game, its genre and style; hence, a responsive feedback
will be passed to the presentation layer for the player to
observe and start the interaction cycle again. Compassion is a
necessity to be practiced at all stages of this cycle in order for
a game to become compassionate.
A. Frame of the Game World
Frame of the game world acknowledges that the player
model overlaps with the game model in creation of the
gameplay experience similar to the discussions on experience
of play in Salen and Zimmermann’s schemas [13]. Schemas
explain how the experiential layer of a game emerges when
Figure 3. When we truly think in a player-centered fashion, it becomes
players play it. The game is governed by the rules that are
apparent that players are very likely not aware of the interconnected system
formal elements of the game grammar and stays same for each that makes the game function.
player, yet the experience of each player is unique as per their
session filtered by their perception. Each player engages with Game presents the current state of the system to the player,
the game world through their perceptions that are mainly this is observed and filtered through the mental model to be
based on their mental model [12]. In this context, the relation judged against motivations and reservations by player’s
between the game and the player is initiated and maintained perception. Once there is a decision or a resolution at player’s
by the player. Therefore, the frame of the game world encloses end, an action is performed by the player via the input scheme
the player as it is activated with the presence and interaction of the game. The game receives this input and magically
of the player.

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processes it. Both decision making process and performing the 3) Reservations: Any reason that prevents a player from
action are taxing on player’s resources. participation is referred within reservations. It may be based
1) Mental model: Mental models refer to thought on previous experience or can be formed at the first instance
processes about how something works in the real world. They of interaction. Barriers to physical activity such as fear of
are formed via observations, or assumptions based on prior injury, poor self-image, low self-esteem or lack of confidence
knowledge. Each person’s mental model is clouded with their to join group exercise activities are commonly reported
pre-judgements and their interpretation of the system [58]. among reasons for lack of motivation for therapies or
There are three models of the system (as adopted from rehabilitation [28][60][63]. Another set of barriers may also
[58]): (1) how the player thinks the game works; (2) how the originate from unfamiliarity with technology, lack of clarity
game is presented to the player as; (3) what the game really is. and ease of use (accessibility) of a system, perceptions on the
Mental model maps to the first model, even before player usefulness of technology, self-image, and fear of failure.
starts any interaction with the system. This resembles the user Therefore, the player model draws attention to the relation
image and the system image concepts of Norman [58]. After between reservations and motivations, and how they may
the first interaction, mental model is reinforced with their influence the mental model of a target user group. As much
continuous interaction. The further the gap between the first as motivations act as a driving force, reservations act as the
model and the last—what player thinks for how the game hand brake. Nevertheless, the game experience needs to be
works versus what it really is and how it works—, the lower fluid and effortless.
is playability—hence the higher is frustration.
A well developed game interface either resembles an C. Player Resources
already known system to leverage familarity or helps the In this context, player resources are considered as the
players to develop a clear mental model of what they can do currency that a player spends during the play session. Each
in this game. Tutorials are generally used as a bandate when individual has finite physical, emotional and cognitive
game is not able to intuitively help players to build a good capacity. Player resources represent this capacity and its
mental model of the system. The ability of the game to suggest availability during gameplay. Rather than the resources
a clear mental model reduces the complexity of interaction commonly discussed as a formal element of a game, the
during stages of the action cycle [12]. Unlike HCI’s common resources referred in this model are intrinsic to a player.
approach of mainly relying on user interface for evaluation of Intrinsic player resources are cognitive skills, motor skills,
usability, for games human action cycle is dispersed over physical abilities and emotional abilities (physical and
gameplay. Therefore, mental model is influenced by three emotional stamina). These are within the power of the player
contextual elements at perception level: (1) the and do not belong to the in-game economy. They are not
contextualisation of actions at goal formation stage of the generated by the game or in the game; however, they are
human action cycle, (2) the procedures and their contextual brought in and used by the player, yet consumed by the game.
presentation at execution stage of the human action cycle, and They are limited, and refresh time for these vary from person
(2) audio-visual feedback and game state presentation within to person. For a suitable design targeting players with physical
user interface (or heads-up display—HUD) at evaluation stage or mental health related difficulties, designers need to study
of human action cycle. These are directly related to the how these resources are effected by the disease and how they
presentation aspect of the interaction layer and indirectly will be used in the game in order to prevent frustration during
related to the information layer as the contextual metaphor is the game.
fed from the core of the game. For example, after long hours of play, the physical stamina
2) Motivations: Elaborating on the aforementioned of a player may drop, and they may not be able to function as
research on player motivation, the purpose of this in the prompt as they were at the beginning of the play session. This
framework is to draw designer’s (researacher’s) attention to is an example of a player spending their physical stamina
the motivations of the player and how they influence their (their physical ability resource); hence, getting tired after a
participation. This should align with not only the purpose of long period of playing. If the player is suffering from anxiety
the game but also the intentions of the player to motivate and the game is designed to alleviate this, the decision-making
participation. With meaning and purpose built in the game, process in the game needs to accommodate that and should
the idea is leveraging the players’ motivation for working not rely on dilemmas as a challenge, dynamics such as time
towards their in-game goals to fulfill the health and trials or quick-time events should be avoided, and visual
rehabilitation goals. This is why PokemonGo (Niantic, 2016) stimuli should be organised to prevent clutter and overloading.
has been praised by health practicioners. For a patient who
D. Interaction Layer
needs to do a descent amount of walking every day, the in-
game goal of hunting pokemons serves the purpose of the Interaction layer represents the overlapping space of game
therapy by motivating the patient to walk since hunting world and player’s world. Via this layer, player sends input to
requires finding the pokemons in the first place. In order to the game world, observes the results of their input and
find them, a player needs to physically walk around until receives a response from the game world. Interaction takes
pokemons appaear in the location based augmented world. place between the player and the game world. It is either
Hence, daily walking activity is fulfilled with the help of the started by the player via an input, or by the game world via an
mobile game. event presented with the presentation layer. When it is
initiated by the player, the game responds; when it is initiated

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by the game via presentation layer, the player responds via • in the form of sound that acknowledges the moment
input layer. In both cases, information layer feeds the and result of interaction (mostly referred as audio
presentation layer with necessary data. Interaction layer is feedback);
composed of presentation layer and input layer. • haptic such as vibration of the controller;
1) Presentation Layer: Presentation layer can also be • in UI including sound and visual effects.
thought as sensory layer encompassing audio, visual and The response fulfills the expectations of gulf of evaluation.
haptic presentation of the current status of the game. This The longer it takes the game to respond or the more
includes continuous presentation of the game world and the disconnected the response is to the current perceivable context
game’s response to the player inputs. Any feedback generated of the game, the larger is the gulf of evaluation. Hence, the
in response to the player inputs is presented by the game usability is lower.
presentation layer. Clarity of presentation and a suitable 2) Input Layer: Input layer is responsible for the
composition of audio-visual elements are essential for interaction device, input techniques, clarity of input mapping,
readability. The presentation of this layer is either (1) active directness, sensitivity and consistency of input. A common
or (2) reactive: goal for a game controller is effortless use with which the
a) Active presentation (1) is initiated and conciously input device feels like the extension of the body [10]. This
generated by the game with respect to or regardless of player motto becomes challenging for special demographics with
positions or existance. It is important to notice that in any impariments or difficulties related to motor skills. For
moment that the player is not interacting with the game, this example, PD has some symptoms, such as tremor,
presentation would still be actively present; hence, active bradykinesia or hypokinesia that may cause difficulty in
presentation. It is an audio-visual presentation for the theme using an input device or perform an input action within a
and of the game world, and would include any audio-visual required time-frame or precision. Therefore, additional
element to inform the player about the current active or research into input devices and interaction modalities would
be useful. Moreover, further research on familiarity of the
passive status of the game including but not limited to
player group, mental model, and restrictions of disease stages
telegraphing for potential actions/events or signalling for
for input modality is expected to improve the design.
awareness of moment-to-moment development of events in In addition to the input device or interaction paradigm, the
the game, score, etc. complexity of input is also important. The complexity of input
b) Reactive presentation (2) is developed in response to refers to the combination of buttons for an input and the
or because of an action initiated by a player, therefore can be characteristics of the combination such as time-specific input,
considered as system’s (game’s) response to the player; simultaneous or ordered button presses, etc.
commonly referred as feedback. Necessary to note that this To reconcile, an effective interaction layer for a
presentation would only be executed if an action that would compassionate game needs to be: 1) immediate; therefore,
trigger a reaction was performed by the player. Reactive presentation layer needs to present the feedback immediately,
presentation can take forms of audio-visual and/or haptic and show the change in game-state if there is; 2) responsive;
feedback directly in response to a player input or to draw therefore, the presentation layer always presents a response to
attention to a change that was a result of the player any input and the player is never left in dark in terms of what
action/input. Audio-visual effects in user interface that is happening with the system; 3) informative; the presentation
inform the player for the moment of change are also examples is readable and clearly presenting all necessary information
of this category. For example, a falling platform would only such as game-state or contextual clues, feedback is clear and
fall (or destructed into pieces with an appealing vfx and sfx) adequate; 4) forgiving; the input scheme allows for a feasible
if the player character walks/jumps onto it. Therefore, audio- input window, error recovery has necessary feedback and is
visual presentation (vfx and sfx for distruction) is a reaction motivational.
to player’s interaction with a game element (falling platform
in this case). If player health changes during this action, an E. Information Layer
audio-visual effect on user interface (one of the hearts Information layer sits in the middle of presentation layer
blinking prior to disappearing) would also be used to draw and structural core of the game, and interprets outputs of the
attention to this change in addition to the update of player core system in a readable format for the player. Cues for
health on screen. Any of the reactionary feedback is time meaning making (semantics), affordances and limitations for
sensitive and loses its value at the end of the perceivable the player [12], contextual visual material, data organization,
window (i.e., 240ms for a full correction cycle). Swink [10] response of the game (feedback for the player), and any
suggests, if a computer’s response takes equal or longer than information, such as score, status, outcomes, etc., belongs to
half of the correction cycle (i.e., 120ms), the systems feels this layer. Even though the information is generated by the
laggy. structural core of the game, its interpretation is handled in
The response of the game world could be: information layer and passed to the presentation layer for the
• in the form of visual effects that shows the moment player to see. Therefore, the collaboration between
and result of interaction (mostly referred as visual information layer and presentation layer carries high
feedback); importance.
1) Contextual Layer: Contextual content works with the
formal elements and supports meaning making. Objectives,

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15

rules, procedures, affordances and limitations become how it is interpreted by the information layer). Therefore,
meaningful with the help of contextual content. While being discoverability, learnability and consistency of the system
important for engaging the audience, contextual content is need to be resolved at this layer so that relevant data could be
also important for maintaining attention and motivation. In fed to the information layer.
order to develop content based on the interests of the target 1) Procedures: Procedures are the first point of
audience (elders, kids, young adults, etc.), a participatory interaction with the input from the player. They are integral
approach or persona studies would be preferable. Salen and to moment-to-moment gameplay, and they define the chain
Zimmermann [13] emphasize that without context, there is no of moves necessary for performance in the game. Reiterating
meaning; hence, contextual meaning helps to develop the previous discussion on correction cycle, a delay in any
meaningful play. For example, Pokemon Go creates a context stage of player performance will make the time-frame of user
around training a special creature called pokemons and input longer. For example, double jump could require hitting
battling to defend your dojo; therefore, one needs to capture the jump button twice within a second in order to perform
the pokemons prior to training them. This means the activities double jump. This seemingly simple action could be
of walking around to find the pokemons, performing the unexpectedly challenging for a person with rigidity or
moves, and using the means to capture them serve within this sloweness of movement, who might find hitting the same
context. The rarity of the creatures, what kind of environment button twice hard to repeat within a second’s window.
they prefer, and how they respond the moves of the player Another example is the number of steps necessary to do
feed into the lore of the game. Swink suggests that the visual something, such as the steps to be performed to bake a cake.
content and the context need to work together with the help For a person with memory issues such as in Alzheimers,
of the right metaphor for a fuilfilling experience [10]. The remembering those would be really hard, therefore frustrating
metaphor represents the connection between context and to perform. Thus, procedures should be catered for a suitable
mental model. grace time, simple recovery (this does not mean game needs
2) Game State: Game state presents any necessary to be easy), shorter and less complex chain of actions for
trackable data that influences players’ decision making while ability to learn and retain information. On top of these,
they are playing. Game state includes but not limited to score, additional consideration for impairments would make a big
item count, health, current or remaining time, active or difference. When done right, the core game demands less
planned tasks/quests, current progress, success/failure, player resources and/or compensates for lack of those when
win/lose, etc. Transparency of game state is necessary to necessary.
ensure competence and autonomy in gameplay. 2) Resources: Management of in-game resources may
3) Feedback: Feedback refers to a compassionate prove challenging if learning, managing and controlling the
reaction that is both contextually suitable and positively resource features of the game are challenging for the players’
perceivable by the player. The positive nature of feedback is resources as per discussion in Section IV.B. Additionally,
emphasized in games for health circles [28][11]. Feedback depending on the way in-game resources are used in the
needs to be focusing on the successes rather than failures. game, an interface complexity may also occur creating
Encouraging continuation of participation and reinforcing additional sensory and cognitive challenges at a level of
flow are within the role of feedback. Necessary to note that presentation layer. For example, games of real-time strategy
feedback can take many forms within a game including but genre are more resource heavy than single screen puzzle
not limited to audio effects, audio-visual changes to the games even though their cognitive complexity may resemble
entities in the game (sound, color changes, color flashes, one another.
outlining, scaling, etc.), animation of entities in the game or 3) Objectives: The role of objectives in game design has
animation at user interface level, visual effects, narration, or already been discussed throughout the article. An additional
any change in the game world, etc. Some important things to note here is on how in-game objectives of the game need to
consider for the attributes of feedback are; how often to show, somewhat serve the targeted health and rehabilitation
how amplified it needs to be, how long it should be shown, benefits of the overall experience. Previously discussed
and in which form (audio and visual) it needs to be. These motivation example on Pokemon Go shows how in-game
attributes should also take into account the capability of the objectives motivate gameplay, and partially serve for the
player (as per the player resources dsicussed before) for a therapy objectives (walking daily). If the therapy objective
compassionate feedback. For example, for a player who can was doing some moves in addition to walking, the game
be disturbed by the nature of visual stimuli (i.e., colour, would have needed these moves performed towards catching
shape, light or change in those), visual feeback should be a pokemon. Besides, objectives should be discernable and
carefully catered not to breach the acceptable visual qualities. achievable by the player considering limited cognitive and
emotional resources may make an objective unreachable.
F. Structural Core 4) Rules: Since the system is governed by the rules,
Structural core of a game comprises formal elements [19]. transparency and consistency of these were already
Both the information layer and the presentation layer are mentioned as necessity. It is important to note that if the
dependent on the core structure of the game while also complexity of the rules prevent the players from
creating meaning for it. From player’s point of view, the core understanding the moment-to-moment gameplay, game fails
of the game may be completely invisible (Fig. 3) as their to be compassionate. The limitations emposed by the
perception is shaped by the presented information (based on

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16

cognitive and emotional resources also shape the player’s on the internal challenges only apparent to the player that are
ability to understand the rules. of a sensitive nature affected by a condition or a disease.
5) Conflict: Conflict in context of compassionate design As much as the compassionate game design concept and
requires additional care. By definition, conflict represents the the paradigm were developed with a synthesis of current
challenge that attempts to prevent a player from reaching work, the player-centric design model should not be
their in-game goals and objectives. This is also what considered to carry any predictive abilities for a best possible
separates digital games and game usability from other system of game based rehabilitation. The development of a
interactive digital experiences. While challenging a player, a compassionate game with the help of the model do not ensure
game presents the player with a problem to be solved and to an effective rehabilitation, nor a single design that is useful for
be overcome. Referring back to motivation and the all kinds of rehabilitation. A planned improvement is
experience of flow, the design of the challenge directly expanding the model with the addition of a set of questions on
affects the playability of the game. Therefore, developing a what to do for each layer, and exemplar design snippets to
suitable challenge and scaling the difficulty for sensitive further help the researchers. Since the bulk of the theory is
demographics is absolutely necessary to motivate play and presented through synthesis now, there is room to develop a
induce flow. Designing the challenge is essentially designing user map or a guide for holistic thinking in future work. In
the game. addition, a report for the application of the paradigm with a
development journal, the resulting product and a postmortem
VI. DISCUSSION AND CONCLUSION is planned for the future. Finally, despite some mentions of
This section shares a discussion and a closing note on the playability, an additional angle with a more detailed
theory and application of the model presented in the paper. playability concept following from existing playability
literature, and a discussion on how playability relates to this
A. On Compassionate Game Design model are in the pipeline of future work.
The idea of compassionate game design emerged during
the analysis of potentially suitable commercial games for C. Conclusion
rehabilitation of PD, followed with an attempt to identify the In this paper, a player-centric design paradigm is presented
sources of the issues found with them [4]. During the to improve game design practice for health-related purposes.
prototyping stage of an exercise game for PD, the building The paradigm is holistic as it draws attention to the
blocks of the player-centric design paradigm surfaced as a interconnected nature of a game experience, the layers of the
nascent theory. Compassionate game design concept is novel game experience to allow a closer understanding of players’
and brave although naïve. The concept has a novel perspective perception of these layers, and some approaches to enhance
to carry the idea of empathy towards a more applicable format empathy for player resources. The paper encloses an analysis
that is much clear for inquiry and contemplation for game of the current literature for similar game design pursuits,
design process. It draws attention to the player’s position in presents a discourse for compassionate game design, and
the game experience, and encourages the researcher/designer explains the player-centric design paradigm in detail with
to examine the design in relation to three areas about the grounding strategies. The main contributions of the work are
player. These are player perception, player resources, and the compassionate game design concept and the player-centric
player-game relation (discussed in Section IV in detail). design model. They are developed to provide an easy to follow
Player-centric game design paradigm is the artefact of the perspective for researchers, who may be new to games for
design research activity that is grounded with the health or who may have limited knowledge about game design
compassionate game design concept. The model aims to be despite a vision on using games for health and rehabilitation
easy to read and apply by anyone without prior game design purposes. The hope is more effectively leveraging the
knowledge. As any novel idea, the way to see whether it is potential of games for this vision with the creation of more
useful for the larger community is by putting it into use and compassionate games.
letting it evolve with the findings.
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