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This article is one of the best, most nuanced takes I’ve seen around mental health on Twitch and I’m honored that I was invited to be a part of it.

Streamers aren’t therapists. But some therapists are streamers.


Game Review: What Comes After

Side-scrolling interactive fiction game exploring topics of grief, loss, life and death.

Content warnings
Nothing graphic or intense, but does acknowledge suicide, self-harm, child death, and pet death. Same CW applies for this article.

Review: Plot and Gameplay
First off, I LOVE the art in this game. It’s super cute without being cutesy or infantile. One of my first thoughts while playing was “this is super pretty”, from the color palette to the scrolling parallax in the background, and distinctive enough that I feel like I could pick it out of a crowd. I also really enjoy and admire when game devs use clever strategies for maximizing art assets. But more on that in a bit.

The story begins with Vivi, the protagonist, as she falls asleep on a train ride home. When she wakes up, she’s still on the train but rather than delivering people to and from work, it’s ferrying souls or spirits of those who have died to their final destination. As Vivi makes her way through the train, she can talk with the variety of souls on the train.

She also meets the conductor (below) and the dining car attendant, each with their own special jobs to do on the train.

The central mechanic of the game is talking with strangers – or talking with their incorporeal forms. Each has a story to tell, sharing perspectives ranging from lives well-lived to petty vengeance.


A second thing I really enjoyed in terms of visuals was the clever use and re-use of art assets. I seriously appreciate when devs embrace limitations and come up with creative solutions. I don’t know for sure if Vivi is wearing a mask because of the pandemic, because of cultural norms, or because it makes life easier to not animate talking. Or all three. Similarly, the spirits don’t even have mouths and their bodies seem largely based on a single form with only slightly different poses.

The general stillness makes movement, when it does happen, carry more meaning. First off, Vivi has the most adorable walk cycle and walking sound effects. Even though masked, she’s expressive in movement and posture. Throughout the game the background zooms by, life quite literally passing Vivi by as the train moves toward death.

Review: Mental Health Content
As called out in the content warnings, this game explores topics related to grief, death, suicide, and self-harm, as well as concepts including acceptance, forgiveness, and meaning. Sometimes the conversations with the passengers felt a little on-the-nose or heavy-handed. Publisher Rolling Glory Jam is an Indonesia-based studio, so it’s possible that cultural or linguistic differences contributed to this feeling for me. That said, putting these kinds of experiences into words is incredibly difficult even for those trained to be able to talk about them. Overall, these mini conversations feel genuine and authentic and I appreciate the variety of perspectives.

I also appreciate how suicide and self-harm were presented. Games often use these as plot twists or as a way to amplify or increase dramatic tension. For Vivi, these thoughts seem normal, part of her everyday. This is particularly powerful because thoughts about death, suicidal thoughts, and self-harm thoughts or behaviors, despite the social stigma and taboo, are pretty common.

24% adults have either thought about or attempted suicide. 55% know someone who has had suicidal thoughts or behaviors.

American Foundation for Suicide Prevention (2018)

The worry that talking about suicide with someone “puts the idea in their head” is a myth, and most people are relieved that someone has noticed and started a conversation. Being exposed to suicide, either through personal connection or media coverage, can increase the risk of suicidal behaviors in persons with high risk factors (e.g. depression) + low protective factors (e.g. few social supports), a phenomenon sometimes referred to as suicide contagion. However, risk is significantly mitigated by HOW information is shared as demonstrated by efficacy studies on suicide reporting guidelines. In other words, the phenomenon of suicide contagion does not occur when suicide is talked about in a careful, honest, and straightforward way.

From Best Practices and Recommendations for Reporting on Suicide

Thoughts of death and self-harm should always be taken seriously but should also be normalized to the extent that it’s acceptable to share those thoughts and behaviors without worrying about being perceived as ‘attention-seeking’, ‘dramatic’, or other damaging label.

For Vivi, these thoughts are born from a difficult home life and issues of self-worth. These thoughts are part of her but she is not her thoughts. But, just like in the real world, her thoughts and experiences do shade and shape her perception of the world around her. Kinda like looking through depression-tinted glasses. Her conversations with the other passengers are an exercise in introspection, questioning long-held beliefs and challenging Vivi (and the player) to look at life from points of view that span lifetimes and even species.

Conclusion: Recommended

I bought What Comes After on sale on Steam $3.99. It runs on Mac and Windows and took about an hour to play. It’s a lovely, straight-forward game that is well-designed, reflective, and thoughtful. I can see myself using this as an example in my Psychology of Games course in terms of content, design, and even content warnings. It has some limitations in terms of depth; as a clinical psychologist conflicts and conversations sometimes felt a bit simple or superficial (as mentioned above) BUT given the scope of the game and that most people who play this game will not be clinical psychologists, the simplicity is appropriate, enables a breadth of interactions, and possibly more opportunity for players connect with the perspectives offered.

presentations teaching

Video Games as Cultural Competence

Everyone plays games, and almost everyone plays digital games. The chances that, as a clinician, the person in the room with you plays video games is quite high; 214 million (64%) Americans are gamers (cite). While not every player sees gaming as part of their identity, many people’s relationship to games and the gaming community carries significant importance.

I floated the idea of a training on games as a form of cultural competence for clinicians back in the Before Times but never heard back. Then, around mid summer, one of the coordinators for the Maryland Psych Association’s conference reached out and asked if I’d be willing to present at the conference.

It’s exciting but also a but nerve-wracking. I love speaking and teaching, and I know I know my stuff when it comes to mental health in games. But that nagging doubt born of graduate school supervisors advising against studying games because “no one will take you seriously” is still there. Grad school was 6 years ago now, but all the stress and anxiety and little tee trauma of finishing that program comes rushing back and reminds me why, after 5 years of grad school, I got my doctorate and then said “peace out” to the field for nearly 5 years.

Not gonna lie though, I’m pretty excited to give a room full of mental health professionals their (probably) first introduction to games as cultural artifacts, to Self Determination Theory, and the gems like this: