Can video games use biofeedback to improve wellbeing?
We have partnered with Playlab London, Complete Coherence and 2CV to design and make a video game for young people that builds habits which increase their long term wellbeing.
Our last blog, written at the beginning of our project, looked at the relationship between video games, wellbeing and emotional regulation. We found that the ubiquity of video games, their engaging design and the fact that some young people were already using them to regulate their emotions all made them a promising platform in which to embed techniques that could increase young people’s wellbeing.
This blog now takes a look at a particular technique we would like to embed into a video game: biofeedback. The technique (described below) is currently being widely studied, with researchers exploring how biofeedback of particular kinds can help improve both physical and mental wellbeing. This blog will look at current research in the field, explore how the technique is already being used in video games, and reflect on what we can learn from these two areas to feed into the design of our final product.
Biofeedback is the process of developing a greater awareness of your body’s activity (e.g heart rate) by being given information on this very activity. The information is usually collected by specialist equipment (e.g. a heart rate monitor) which effectively lets you “see" or "hear" the activity inside your body. Using this information you can then learn how to change or control this activity in everyday life.
For example, you could be shown your heart rate on a screen and then be placed in a purposefully stressful situation. When your heart rate shoots up in response to the stress, you could practice lowering it, with the screen display letting you see what is effective at changing it and what makes no difference. Once you have practiced this, you may then be able to consciously lower your heart rate and respond more calmly when someone spills red wine on your brand new cream carpet.  
An interesting type of biofeedback: heart rate variability
A type of biofeedback of particular interest to We Are What We Do is heart rate variability (HRV). HRV is how different the gaps between each heartbeat are. To understand this measure you first need to know that there is actually not an equal gap between each heartbeat. For example, an average heart rate of 60 beats per minute does not mean that the interval between each heartbeat is exactly one second. Instead, the gaps could vary with some lasting 0.5 seconds between beats and others lasting up to two seconds between heartbeats.
Although it seems counterintuitive, research has found that the greater the HRV (so, the more difference there is in the gap between each heartbeat), the better. A greater variability of heart rate shows that the body is able to respond quickly to different signals that the nervous system is continuously sending to the brain and the heart and adjust the heartbeat speed accordingly. If the heart rate doesn’t vary much, and the gaps between the beats are very even, it shows that the body is not able to adapt to the signals being sent out.
How heart rate variability affects your health
Numerous studies have shown that greater HRV is associated with a lower risk of a range of illnesses including hypertension , diabetes  and sudden death from heart attacks.
Along with physical benefits, greater HRV has also been linked to psychological health with research showing that healthy participants tend to have greater HRV than those with anxiety disorders and alcohol addiction. Studies have also found a relationship between HRV and a person’s social behaviour, with less HRV being linked to a lower motivation to engage in social situations, less ability to self-regulate and difficulty dealing with stressful situations.
The associations between HRV and psychological wellbeing have led to HRV being called a psychophysiological marker of mental wellbeing, as by measuring a physical state we are able to understand a bit more about the person’s mental wellbeing. From a measurement perspective this is very handy, as accurately measuring people’s internal mental states is notoriously difficult. Whereas measuring a heart beat is seemingly simple in comparison.
Nothing is set in stone
If you are reading this and starting to worry about how much your heart rate varies, never fear, as HRV looks to be responsive to training. Researchers have found that by giving participants biofeedback on their HRV (showing them their HRV as a pattern on a graph) participants increased their HRV, with some interesting consequences.
For example, studies on anxiety found that using HRV biofeedback has, in some cases, reduced the anxiety levels of college students when used on its own  or in conjunction with counselling . Studies with depressed people also showed that HRV biofeedback was effective in reducing their level of depression and this improved level remained after the treatment. 
Within the realm of competitive sports it’s been found that giving biofeedback to athletes increased their HRV and in turn improved their sporting performance e.g. improving a team’s batting performance in baseball. 
The link: Biofeedback, HRV and video games
So, what’s all of this got to do with video games. Well, We Are What We Do set out to design a product or service to improve the mental health of young people. As the sections above explain, HRV appears to have a strong relationship with mental wellbeing, is also capable of being changed through breathing and biofeedback and is relatively accurate to measure. Since previous research we did showed that video games were a good platform to embed techniques into to help young people improve their wellbeing we put the two ideas together and started to think about how to incorporate HRV biofeedback into a video game .
HRV biofeedback is already being used in some video games. For example, in the Wild Divine game a sensor attaches to three fingers and measures both HRV and skin conductivity. The sensor “talks” to the video game allowing the player to direct what happens on the screen using biofeedback, for example, by relaxing and lowering their arousal the player is able to move items around the screen e.g. lower a feather onto a pillow. The game is explicit in its focus on using biofeedback technology to increase well being through meditation and relaxation with its most recent release, Zen Journey, including an on-screen Zen master to coach the player through tasks. Such a game is clearly intended for an adult audience who already have an interest in wellbeing.
Other games, such as the horror game Nevermind, have built HRV biofeedback into the actual plot of the game. In Nevermind the player explores the twisted world of the subconscious. As the player progresses through the game and completes tasks, the biofeedback sensor monitors their HRV to measure how scared or stressed they become moment-to-moment. If the player lets their fears get the better of them, the game gets harder.
Although this game has more appeal for young people, it doesn’t give the player any training on how to improve their HRV, instead the player is purposefully left to work out for themselves what techniques work to calm them down in times of stress.
Working with Playlab London, Complete Coherence and 2CV, we are now exploring the challenge of building a video game in such a way that it both coaches the young person to increase their HRV but is still engaging, entertaining and attractive to young people.
We will be updating this blog with our progress in the months to come and look forward to sharing the creative ideas that are emerging around this challenge. If you would like to get more information on the project, please do get in touch with us by emailing Naomi.firstname.lastname@example.org.
 For a review of techniques that increase wellbeing see our Survey of products and services which promote wellbeing, http://cl.ly/0V2M313S2X2H
 Biofeedback Certification International Alliance (2012) Overview of biofeedback. Retrieved from http://www.bcia.org/i4a/pages/index.cfm?pageid=3524
 Calderon, K.s., & Thompson, W.W. (2004) Biofeedback relaxation training: a rediscovered mind-body tool in public health. American Journal of Health Studies, 19, 185 - 194.
 Schroeder, E., Liao, D., Chambless, L., Prineas, R., Evans, G., & Heiss, G. (2003). Hypertension, blood pressure, and heart rate variability: The Atherosclerosis Risk in Communities (ARIC) study. Hypertension, 42, 1106–1111.
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 Kemp, A.H. & Quintana, D. S. (2013). The relationship between mental and physical health: Insight from the study of heart rate variability. International Journal of Psychophysiology, 89, 288-96
 Henriques, G., Keffer, S., Abraham, C. and Horst, S. J. (2011). Exploring the effectiveness of a computer-based heart rate variability biofeedback program in reducing anxiety in college students. Applied Psychophysiology and biofeedback, 36, p101-112
 Ratanasiripong, P., Sverduk, K., Prince, J., & Hayashino, D. (2012). Biofeedback and counseling for stress and anxiety among college students. Journal of College Student Development, 53, 742-749.
 Karavidas, M., Lehrer, P., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S., et al. (2007). Preliminary results of an open label study of heart rate variability biofeedback for the treatment of major depression. Applied Psychophysiology & Biofeedback, 32,19–30.
 Strack, B. W. (2003). Effect of heart rate variability (hrv) biofeedback on batting performance in baseball. Dissertation Abstracts International: Section B: The Sciences and Engineering, 64, 1540.
 For further information on the relationship between young people’s wellbeing and video games see our previous report here: http://cl.ly/2l0S2K0w1b17