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It took 4 weeks for me to drop the ball on timely updates, but considering all that’s been going on I’m taking it as a win that it’s only a week late. On Feb 1, I started full time as a practicing psychologist. Full time clinical + part time program management with Take This, and adjunct teaching a brand new class has been a lot to handle but, like Tim Gunn, I’m gonna make it work.

Honestly, the most challenging thing about the class is finding that balance between psych and games. I talked about it more in depth in my last post, but it bears repeating that figuring out what is within scope and what is unnecessary is incredibly tricky. This was made especially clear this week with the anxiety unit.

For their homework, my students were to play or otherwise review Fractured Minds, an award-winning autobiographical-ish game by Emily Mitchell. We had some extra time in class so I figured we could play in person a bit as well. As always, I reassure my students that their feeling of comfort and safety is paramount and that if anyone needs to step out, take a walk, put in headphones, etc that I welcome them to do so. I say this so much, they probably have recurring dreams about it. I 100% believe that not only is this kind of content warning and emotion management key to ethical practice, but walks-the-walk in terms of self-care.

I just didn’t expect nearly half my class to walk out.

To be clear, I’m glad they did. Ecstatic. The worst thing would be for someone to sit there, suffering. But I was truly surprised and took a long time reflecting on it. Had I missed something? Were the content warnings lacking? Is my perception of what’s “upsetting” skewed? Whatever the answer, I felt terrible and spent time talking with each student, checking in, and making sure they were ok.

In a way I’m glad it happened since this upcoming week, Week 5, is about psychosis and the game of the week is Hellblade. I’m now hyper sensitive to the boundaries my students have demonstrated and hope that I’ve made appropriate changes. The largest being that, for this upcoming class, I notified students that the second half of class – where the gameplay happens – is voluntary and that anyone who wants to go home after lecture is welcome to do so. This decision was definitely influenced by what happened with Fractured Minds, a much less intense game, but also my replay of Hellblade.

I honestly don’t remember Hellblade being so graphic, so intense. I thoroughly enjoyed my play-through but it was a different experience playing with the purpose of screening for others. Even the parts I recalled being pretty chill were still graphic, intense, or potentially upsetting. I hope some students go home and I hope some stay to play and have a deep discussion on the game, but we’ll all have to stay tuned to find out.

Anyway, this is supposed to be a post about anxiety in games… We started with the normal stuff – definition, description, and diagnoses. Although I didn’t (couldn’t) highlight every anxiety disorder, I did manage to find a character with Agoraphobia and continue to feel particularly proud of myself for that accomplishment.

The majority of the applied focus to games centered on PTSD. PTSD is pretty common in games. Some of the reasons we discussed included 1) PTSD is a “hero’s” disorder; 2) Symptoms of PTSD are easier to convert to visual representations; 3) PTSD requires a traumatic event.

Although all mental illness is stigmatized, combat PTSD is publicly viewed as one of the more “acceptable” mental illnesses (important: even so, combat PTSD is still heavily stigmatized, especially within the military). To the lay population, combat PTSD means you did something brave, served your country, etc. In a really gross way, it’s used often as like a badge of honor in storytelling. Tons of games feature combat PTSD, likely because many games are focused on combat. The wounded soldier seeking vengeance or returning home is a well-worn trope. But non-combat PTSD, PTSD related to things like surviving assault, domestic violence, or natural disasters is far rarer. Best guess? Combat PTSD = strength/bravery (coded male), non-combat PTSD = victim (coded female), regardless that both are debilitating and developing PTSD has nothing to do with any of those attributes.

Second, the symptoms of PTSD are easier to portray in a visual medium than something like depression. Flashbacks, a legitimate symptom of PTSD, are a super useful story-telling device, and other symptoms, such as hyper-vigilance, are also simple to portray through narrative or other visuals. They’re also “action-y”, used to move the story forward, share internal thoughts, and be visible to the player and NPCs.

Lastly, trauma is in the name. Post-Traumatic Stress Disorder. The use of trauma as a plot device or character development is rampant in most media and games are no exception. Notable examples include Max Payne and Deus Ex: Human Revolution which both use the death of a wife or daughter, respectively, as a substitute for a backstory and the justification of the protagonist’s action. In fact, the harming or killing of women as a catalyst for the male protagonist’s story arc is so common it even has it’s own named trope: Fridging.

Next, we reviewed some of the current research on the use of video games as a means for treating anxiety including a study on Tetris as a way to prevent PTSD, the use of biofeedback in games like Nevermind and Mindlight, and less formal reflections on the use of casual games as anxiety management.

Next up, I loaded Fractured Minds and you already know how that went. After checking in with students and a brief break, we pushed on and played Celeste. I had students play through the very start of the game as well as the gondola scene. For those unfamiliar, about halfway through the game the main character and her friend take a gondola toward the summit of Celeste Mountain. Halfway up, the gondola breaks down and Madeline, the protagonist, experiences a panic attack. Her friend Theo names the experience as dark tendrils replace a previously peaceful scenic background. Theo says his grandfather taught him a trick to help him calm down, and what follows is an abbreviated and game-ified version of a breathing technique. The player uses the controls to keep an imagined feather within a specific frame as it floats up (inhale) and down (exhale).

From a clinical perspective, it’s far from perfect. For example, the pace of the feather floating up and down was a bit quicker than I’d recommend and, technically, the player is just using controls rather than actual breathing. It’s also important to realize that for some people, paying attention to their breathing can actually increase anxiety. That said, having a technique like that represented in something as public and accessible as a popular video game is exciting, encouraging, and normalizing. I wouldn’t be surprised to hear one day to hear a news story about how someone helped themselves or a friend through intense anxiety because they remembered this moment in Celeste.

During discussion where we compared portrayals in Fractured Minds to that of Celeste, it was once again brought up that the smaller, more memoir-type games seemed more intense and designed to share the visceral experience while the more abstract, more professional games were more about the concept, about providing a more generalizable experience. This does seem to speak to the differentiation between some games as personal expression, almost a therapy unto themselves, and some games as entertainment-driven but conscientious of their content. The world definitely needs both and this feels like a dissertation waiting to happen (I’ve served my time; this dissertation is on someone else).

Next week: Psychosis and Personality Disorders in Games

Readings:

• VentureBeat. (2017). Hellblade: Senua’s Sacrifice documentary. 

• Fordham, J. & Ball, C. (2019). Framing mental health within digital games: An exploratory case study of Hellblade. JMIR Mental Health, 6(4).

• Lindsey, P. (July 21, 2014). Gaming’s favorite villain is mental illness and this needs to stop. Polygon. Roxby, P. (Nov 24, 2017). Avatar therapy ‘reduces power of schizophrenia voices’. BBC News.

• Avatar therapy ‘reduces power of schizophrenia voices’. BBC News.

Students were also tasked with emailing me questions in anticipation of our upcoming section on gaming controversies. I’m looking forward toward reading their questions and working that into weeks 6, 7, and 8.

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

Yesterday was the first real test of my experimental course structure and it went as well as I could have hoped. For homework, students were required to read:

• Representation of Mental Illness in Video Games
• Framing Mental Health within Digital Games: An Exploratory Case Study of Hellblade
• Gaming with Stigma: Analysis of Messages About Mental Illness in Video Games
• Why Representation Matters in Video Games

Students were also required to either play or watch a walkthrough of The Elder Scrolls IV: Shivering Isles, a 2007 expansion to The Elder Scrolls IV: Oblivion. The premise of Shivering Isles is that Lord Sheogorath – Deadric Prince of Madness, The Mad God – is seeking a champion to defend his realm, the bifurcated land of Mania and Dementia. Not exactly subtle in terms of mental health references, but it’s week two and like any good game onboarding I wanted to make it pretty much make feeling successful and competent almost guaranteed.

Before class, students sent me a brief email with three observations from their play or walkthrough about what psychological or mental health portrayals they noticed. This assignment was one part easy points, one part familiarity check, and one part accountability check.

At the start of class, I spoke for about an hour about, high-level, mental health, mental illness, and why game devs should care about it.

I talked about research pertaining to stigma and stereotypes in media as well as specifically in games. The Ferrari et al article referenced above was one resource as was a 2016 study by Shapiro and Rotter that found, of the 90 or so AAA titles they studied, 25% portrayed a mentally ill character. In other words, devs need to care because mental illness is already pretty common in games and that these portrayals can have an impact. Specifically, perpetuating negative and harmful stereotypes about mental illness in media has been linked to decreases in willingness to seek treatment, and increases in self-stigma, discrimination, and marginalization.

Before I go any further, it’s important to emphasize that I do not believe people, when playing a game, take in and accept wholesale whatever they see. Playing games doesn’t make people violent (all the research), largely because we know 1) it’s not real and 2) we’re taught from infancy that violence is bad. We can enjoy these violent games precisely because we understand that it is pure fiction. It’s different with mental health, however. Unlike violence, most people do not receive any kind of education, either from loved ones or through the school system, about mental health. In fact, the #1 public resource of information about mental health is digital media – television, movies, the news, and games – and none of those mediums have a great track record with how they depict psychopathology.

For example, when mental illness is discussed in the news, over half the time it’s in relation to acts of violence; only 7% of news coverage of mental health mentions successful treatment or recovery. Because talking about mental health and sharing experiences related to mental illness continues to be significantly stigmatized (one of the top 3 reasons people don’t seek help, right after cost and geography), we don’t talk about how a person with a mental illness is 10x more likely to be the victim of a violent crime that someone without a mental illness or how persons with mental illness account for only 3% of all violent crime committed. What we’re left with is an enormous chunk of the population who have never been taught about mental health and whose main source of information is what is shown on a screen. 

So, back to class! After lecture (and a break), it was game time. I’d spent almost the entire previous week replaying Shivering Isles and taking notes, so for class I brought in my Xbox One and had the perfect quest set up. Fittingly titled “Addiction”, the quest involves exploring Dunroot Burrow in to retrieve the Chalice of Reversal for Thadon, Duke of Mania.

The Chalice balances out withdrawal from Felldew, an addictive narcotic akin to cocaine or other uppers and a favorite pastime of Thadon’s. In order to enter the Burrow, the player must take some of the drug. The drug has an instant effect of buffing stats related to health and strength and the player gets a “Felldew Euphoria” notification. After a short while, however, the effect fades and the player begins to experience withdrawal; in this case, a decrease in attributes like strength, speed, and carrying capacity. Players need to continually take Felldew, which has limited availability throughout the burrow, to maintain their stats until they find the Chalice (and slay the “Felldew Addicts” that protect it).

During class, we’d discussed the portrayals students had noticed from their homework, mostly talking about character depictions, environmental design (e.g. naming the land Mania and Dementia), how “normal” NPCs treated those who had spent time in the Shivering Isles. But I saved the discussion on mechanical representation until after the play-through. I always find it hard to talk about how mental illness, or at least its symptoms, can be manifested in game mechanics and in what the player actually feels and does.

During the class play-through, I watched as students began to figure out what was going on, how the person playing began to look more stressed and at one point stated, “I need to find more cocaine!” (aka the Felldew). During play I actually asked the student who bravely volunteered to be the player how they felt, to which she said she felt more and more stressed as the burrow became more confusing and the Felldew harder to find.

At one point, the withdrawal took down the player’s carrying capacity which meant she had to sort through the inventory to find things to drop. Because this wasn’t her character and she hadn’t put time into building the inventory, it wasn’t a big deal. However, when I had my spouse play through this part (for science of course), he was quite precious about his inventory and, when forced to drop items, seemed distressed. He described it as, “I had to give up things that were important to me. I had to make hard choices.”

We talked about all of this until the end of class, how this particular mission was designed to provoke feelings similar to those an addict may experience. Feelings of stress, discomfort, confusion, disorientation, anxiety, giving up things, and making hard choices. Obviously this is not a one-to-one experience for what someone living with an addiction experiences, but it’s a flavor and generated interesting conversation around how we talk about drug addiction and the term “addict.”

Next week, we start a section that digs deeper into specific mental disorders and their in-game portrayals. Readings for next class are:

• Night in the Woods: A review
• I want more depressed video game characters: Here’s why
• Playing autobiographically with depression

Students have also been asked to play Depression Quest on their own and to review Sea of Solitude as that’s the game we’ll be playing and discussing in class.