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      When we play games, we’re not just paying attention to the game—we’re paying a special quality of attention. That quality is called flow.

      Flow is the state of being completely cognitively absorbed in an activity. It’s not mere distraction or engagement; it’s full engagement. It’s being totally immersed in, motivated by, and energized from the challenge at hand. In a state of flow, you not only lose track of time, you lose a sense of self-awareness. You experience a “deep focus” on the activity and no conscious awareness of competing thoughts or emotions.¹⁶

      First identified by American psychology researcher Mihaly Csikszentmihalyi in the 1970s, flow is considered an extremely positive psychological state—indeed, perhaps the most optimal psychological state.¹⁷ A flow state can be achieved in many different ways, as long as the right conditions are met. It emerges when we have a clear goal, a challenging task to perform, and sufficient skills to meet the challenge—or at least to come close enough that we are energized to try again and do better. People find flow playing guitar, cooking, running, gardening, doing complex mathematics, and dancing—to name just a few ways. However, compared with a quick video game, these activities aren’t always as easy to perform in stressful contexts and everyday environments (and definitely not in an operating room before surgery). Moreover, when Csikszentmihalyi first wrote about the phenomenon of flow, he identified games and play as the quin­tessential flow activity.

      Perhaps surprisingly, many leisure activities that we commonly think of as a good source of distraction do not typically lead to a flow state: watching television or movies, listening to music, or even reading.¹⁸ While these may be pleasurable and can indeed take our mind off our problems, they are not usually challenging and interactive in the way that flow-inducing activities must be. This is an important insight, because many people nat­urally turn to relaxing activities as a way to deal with stress, anxiety, or pain. But flow research shows that a challenging interactive task actually gives us more control over what we think and feel than a passive relaxing activity.

      Flow is the reason that games, more than any other activity, are uniquely able to help us exert more control over anxiety and many other emotions as well. Games give us a clear goal. They require focus and effort to succeed. And digital games provide near-constant feedback so we can improve our performance. As soon as we improve our skills, the game gets harder, ensuring that we are always sufficiently challenged. Video games are such a reliable and efficient way to reach a flow state, in fact, that when scientists want to study the phenomenon of flow in the laboratory, they typically have participants play them.¹⁹ No activity that we know of creates flow more quickly, for so many people, as digital game play. And when we are in flow, we are in full control of our attention spotlight.

      If you can create flow for yourself, you’re not just blocking negative feelings like pain and anxiety. You’re also actively creating better psychological and physical health.

      Scientists at the Psychophysiology Lab and Biofeedback Clinic at East Carolina University recently completed a series of three studies to measure the mind-and-body impacts of video game play. They were interested in one particular genre: casual video games, the simple single-player ones like Angry Birds, solitaire, and Bejeweled. They can be learned quickly and are easy to stop and start again. They are highly correlated with flow states.²⁰ And unlike more complex games, such as World of Warcraft and Madden NFL Football, they require no special video game skills, expertise, or regular time commitment.

      The scientists’ interest in casual video games was sparked when a senior executive at PopCap Games, one of the largest casual game makers in the world, shared findings from a formal survey of its players. It turned out that 77 percent of players were seeking some form of mental or emotional health benefit from playing, not merely entertainment.²¹ These players reported using casual video games to improve their mood, stop anxiety, and relieve stress, and in some cases even as a kind of “self-medication.”

      Were the players’ mental health benefits real or imagined? That’s what PopCap wanted to find out. So it created a research program with East Carolina University (ECU), known for its leading biofeedback research. The goal was to measure changes in brain waves, heart rate, and breathing patterns in game players to see if they aligned with physiological signs of improved mood, decreased depression, and resilience to stress.

      The scientists at ECU attached monitoring devices to game players in order to track two specific measures of emotional and physical resilience: electroencephalographic (EEG) changes in alpha brain waves, which can indicate whether you’re distressed, depressed, or in an overall good mood; and heart rate variability, which reflects how quickly your body can recover from emotional or physical stress.

      The group’s first randomized, controlled trial found that a twenty-­minute session of casual game play decreased left frontal alpha brain waves, which typically indicates improved mood. Indeed, on a survey, the players with decreased alpha brain waves reported feeling in a better mood. They had significantly less anger, depression, and tension and more energy. A comparison group that simply surfed the Internet for twenty minutes had no significant EEG changes and no reported improvements in mood or energy level. The game players, meanwhile, also experienced significant improvements in heart rate variability. After just twenty minutes of play, their hearts were able to withstand more stress and recover more quickly.²²

      These initial findings were so promising that the team decided to conduct a longer-term study of casual video games. In their next trial, they studied the impact of thirty minutes of game play, three times a week, on reported mood, as well as on the same EEG and heart rate variability measures. Participants were all suffering from anxiety, depression, or both at the start of the study. After one month of this game play routine, they saw significant reductions in depression, anxiety, and general stress levels across the board. Their EEG and heart rate variability measures—both significantly improved—confirmed these perceived emotional changes at a physiological level.²³ As a result of these significant findings, the researchers have called for the development of prescriptive interventions.

      Someday soon it’s quite likely that psychologists or doctors will commonly write prescriptions for Angry Birds to reduce anxiety, or Peggle to treat depression, or Call of Duty for anger management. Indeed, I already frequently hear from therapists and counselors who do just that! And the science is increasingly on their side. A 2012 meta-analysis of thirty-eight randomized, controlled trials of video games published in the American Journal of Preventive Medicine found significant promise for video games to improve psychological health outcomes. (The article also encouraged researchers and the game industry to conduct trials of longer duration as a necessary next step for this emerging field of research.)²⁴

      Keep in mind that gameful prescriptions are not necessarily an alternative to traditional forms of therapy or medication. Indeed, 23 percent of participants in the ECU casual games trial continued to take antidepressants during the study. We are still at the beginning of understanding the full range and depth of the positive impact that games can have on our health and well-being. For now, and perhaps for the long term, these tools should be seen as a complement, and not necessarily as an alternative, to other forms of support and treatment.

      Game play isn’t the only flow activity that can lead to these positive mind-and-body results. As you start to practice the gameful techniques in this chapter, you’ll become better and better at spotting a wide range of activities that help you tap in to your natural ability to control your attention.

      Mindfulness meditation, for example, has been measured to have quite similar physiological benefits as casual game play. During mindfulness meditation, participants are challenged to focus on their breath above all other thoughts, emotions, or physical sensations. This is actually quite a difficult task that requires a tremendous amount of attention! If you’d like to try it, set aside a few minutes where you can sit quietly and simply count your breaths. Each inhalation and exhalation counts as one breath. See how high you can count before you realize that you’ve been distracted by a thought or sound or feeling and lost count. Start over from zero and try again. Continue trying to increase the number of breaths

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