CONTENT WARNING: This post contains references to mental illness, depression, grief, and suicide. There are no explicit descriptions or graphic depictions, however these topics are discussed in reference to their existence in the physical and digital worlds.
Over the past two weeks, I’ve been introducing students to the concept of the science of psychology and representation in games from a pretty high level. This week, however, was our first deep cut into mental health and where it intersects with digital games. I started with depression partly because it’s one of the disorders I’m most familiar with as a psychologist and pretty frequently appears in games, and partly because it’s so misunderstood.
Talking about mental illness is hard. It’s something I’ve been doing for over a decade and, although it’s become easier overtime, it’s never easy. At the end of last class I let my students know what they could expect when we talked about depression, and first thing in class I re-stated content warnings.
This is how every class starts when mental illness is a topic. I want students to know up-front what they’re in for and, just as importantly, give them options on how to manage potential discomfort. I always tell my students at the start of class that if at any point they feel uncomfortable or unsafe, that they should “do what you need to do to take care of yourself” and provide examples such as: put in ear buds, zone out on Twitter or Insta, close their eyes or put their head down, get up and take a walk. “This stuff is hard,” I say, “And I won’t be angry or feel bad if you get up and get some air. Take care of yourself so you can be present for the parts of class where you can be.”
For some it might seem like overkill, but experiencing activated symptoms of mental illness AND feeling like you have to stay put and “deal with it” is awful, harmful, and cruel. Been on the receiving end of that; do not recommend. My hope is that this repeated mantra of self-care, not just as an ill-defined buzzword but as a genuine and earnest recommendation complete with suggestions, creates a feeling of safety for my students. In terms of informed consent, I do my best to practice what I preach.
Speaking of ethics, here’s the second slide from class.
Something new to this course, and to my teaching in the Game Lab overall, was an introduction to clinical (or abnormal) psychology. I had a long and intense debate with myself over whether or not to discuss depression, and all the other diagnoses we’ll be covering, from a clinical perspective including diagnostic criteria, prevalence, and treatment. I especially wondered if my game design students would even care. Does a future game designer really want or need to know that a diagnosis of major depression requires low mood almost all day, almost every day for at least two weeks along with at least five out of nine possible symptoms?
Ultimately, I decided to include it and after last night I feel confident that it was the right choice. First off, the criteria for all mental illnesses are publicly available, so it’s not like I’d be sharing some secret knowledge. In fact, by reviewing the diagnostic criteria, I made intentional efforts to translate any jargon, clearly state what each criteria or symptom meant, and provide examples. Similarly, I dedicated two entire slides to busting myths about depression and providing information you likely wouldn’t find on the depression Wikipedia page, things like there being between 277 and 10,000 different variations of depressive symptoms*.
My class is pretty quiet during lecture, but when talking about the diagnostics of depression there were lots of questions. Even students who rarely, if ever, voluntarily speak were visibly engaged and asking questions. I felt like this is where I really hit my stride as 10 years of psychotherapy experience and training just popped right back up like a weed in summer.
Once the foundation of depression was laid, I shifted into talking about depression in games. Or, more accurately, 4 different ways of examining games and depression:
- Games about depression
- Depression in games
- Treatment games
- Games as treatment
First we talked about games about depression. These are largely autobiographical narrative experiences wherein the author is sharing a very specific type of depressive experience. As homework, students played Depression Quest and we discussed that as an example of a “game about depression.” The main takeaway being that Depression Quest uses both mechanics and narrative to drive home a very specific experience of depression. As one of my students said, “It felt like reading someone’s diary.” We talked a bit about why this game was important and also why no one liked playing it; the discomfort is the point. Other games about depression I highlighted were Actual Sunlight and Elude.
Second, I defined “depression in games” as games that portray some element of depression through story, mechanics, environment, context, etc. These are games that are less autobiographical and take a more high-level view of things like depression, grief, and suicide. The main game I focused on for this section was Stardew Valley.
Stardew Valley is a farm-based role-playing game with an absurd amount of interaction opportunities. Two characters in the game seem to express depressive thoughts; Sebastian displaying some mild hopelessness and lack of direction, while Shane is quite obviously suffering from depression. Shane even expresses suicidal thoughts at one point in the game after passing out from an alcoholic bender. On one hand, this story seems a bit out of place in a game that is largely played as a means for relaxation. On the other, however, it can also be read as hopeful in that Shane recovers from his depression and alcohol abuse. It’s worth noting that recovery from metal illness is pretty much unheard of in any kind of media portrayal. Other game examples included Child of Light, Gris, Oxenfree, Unfinished Swan, Tiny Tina’s Assault on Dragon Keep, and Life is Strange.
A special note about Life is Strange. I specifically mentioned this game because of the interaction between Max, the protagonist, and her NPC friend Kate Marsh. [Spoilers ahead] In the second episode of the game, Kate Marsh stands on top of the dorm building preparing to die by suicide and it’s up to the player – and their dialog choices – to prevent it. The first time I played through, I saved Kate but what never occurred to me was that it was possible to fail. I was literally unable to conceive that someone would create a situation like that, where the player is responsible for the suicide of character without a content warning or heads up of any kind.
I’ve lost friends to suicide, a lot of people have. Thinking back, I’m not sure I would have continued to play the game had I not saved Kate, or had I realized not saving her was a possibility. There’s a lot of things in Life is Strange that I wish the developers had created content warnings for, or opportunities to skip. I mean, even Call of Duty gives players advanced notice and the opportunity to skip content that is considered troubling. Not only was there no warning, but this interaction was one that could not be undone ostensibly because the “rewind” power that Max had been using to set things right was too painful at that time. Alternatively, it was a decision the developers made to up the emotional ante and really stick it to players’ feels.
While researching Life is Strange, I found an exchange on a reddit thread discussing whether or not the game should have trigger warnings and, on average, this is was the general consensus:
Ugh. As I ranted about in my Games for Change talk last year on empathy in games,
Distress =/= Empathy
Trauma is not a plot twist
Since, to my knowledge, the ethics of portraying mental illness in game design isn’t a course that exists anywhere, I tend to spend time every class talking about ethical representation and I definitely spent a bit of extra time yesterday going over depictions of suicide, self-harm, and responsibility to the player.
Next, we shifted to talk about treatment games; games specifically designed to augment or enhance existing mental health interventions. Naturally I talked about SPARX but also shared the mixed findings in terms of research around it. I also talked a bit about EVO, a game that is currently being reviewed by the FDA and has the potential to become the first prescribable video game.
Lastly we went over games as treatment. These are games that weren’t designed with a therapeutic use in mind but have been co-opted to serving that purpose. These range from casual games like Pokemon Go and Peggle to hardcore games like Dark Souls. The idea here being that games we love are feeding more than just our interests, they give us something we’re lacking in the physical world. For example, one of the strategies for confronting depression is to get a person up and moving, a strategy referred to as behavioral activation. Persons with depression also tend to be socially isolated for a variety of reasons and that isolation can exacerbate depression. Then you look at something like Pokemon Go and how the game demands movement and encourages socialization and for people who enjoy Pokemon, that can be enough of a nudge to get them started.
Similarly, puzzle games like Peggle and Bejeweled can offer players a convenient and confidential means to experiencing small victories throughout their day. As a therapist, getting a client struggling with depression to 1) do something they enjoy or used to enjoy and 2) all but ensure a successful experience is super helpful. There’s also a super deep rabbit hole around the use of Dark Souls to fight depression and I recommend taking a look. Although most of these games aren’t backed by studies, there are near infinite anecdotal accounts of how commercial games have made a positive impact on the mental health of players.
Finally, I talked about the research around the potential negative impact of video games on mental health. To be perfectly honest, games and psychology research is a dumpster fire and there’s nothing clear to say other than games can be used to positive or negative effect. A hammer hitting a nail is doing a good, helpful thing, but that same hammer can also brain someone which is not good. It matters what and why you use it. It seems to be the same with games. If you’re using games as a way to connect with friends, to relax, or to vent, there doesn’t appear to be any problematic reaction. However, if someone is using games to continuously avoid facing problems in their life, if it’s the only way they have of socially connecting, or if they use games as a form of self-medication, then there does seem to be a negative impact.
In other words, playing games isn’t going to solve your problems but they can be used as a coping tool. Not necessarily the most helpful or effective coping tool, but a coping tool none the less.
After break, I loaded up Night in the Woods for the class play-through.
I’d really struggled to figure out what section of the game to have students play in class. No one part really seemed strong enough by itself to examine Mae’s depression, but that’s also kind of the point of the game. I decided to have a student play from the beginning right up until band practice with Greg. While we played, we discussed things that we were seeing that were related to how depression was being portrayed. This included Mae’s flat response to things that most would find upsetting, her thrill seeking that one student described as her attempt “to feel anything”, and another student pointing out that, unlike other platformers, most of the action in the game starts to the left, suggesting a regression in time for Mae to a younger self.
After the play through, we discussed the game a bit more, especially in contrast to their experience with Depression Quest. We were only able to play in class for about 40 minutes which isn’t nearly enough to get into NitW. They did, however, have an assigned reading about NitW and all that combined enabled us to have a comparative discussion of the two and examining how these two very different games portray a similar condition and what the experience is for a player between “reading someone’s diary” and a more abstract representation. Both have merits, of course, and I ended by encouraging students to think about how the two games made them feel, what would stick with them, and how those experiences might impact their designs in the future.
Next week readings and assignments!
Stanley, A. (Nov. 7, 2018). The therapy and anxiety I recognized in Celeste. First Person Scholar.
Smethurst, T. & Craps, S. (2015). Playing with Trauma: Interreactivity, Empathy, and Complicity in The Walking Dead Video Game. Games and Culture 10:3, pp. 269–290.
Jorgenson, K. (2016). The positive discomfort of Spec Ops: The Line. Game Studies 16(2).
Takahasi, D. (Nov 14, 2019). 17-year old’s Fractured Minds mental health puzzle game debuts on PC and console.
PLAY: Fractured Minds