Teaching about mental illness through play
Part 1 — A Quest for Understanding
The goal of this game is twofold: firstly, we want to illustrate as clearly as possible what depression is like, so that it may be better understood by people without depression. Hopefully this can be something to spread awareness and fight against the social stigma and misunderstandings that depression sufferers face. Secondly, our hope is that in presenting as real a simulation of depression as possible, other sufferers will come to know that they aren’t alone, and hopefully derive some measure of comfort from that.[1]
This statement from the opening screen of Depression Quest lays out a vision for the possibilities of interactivity as a mechanism for teaching about mental illness. The agency that games bestow upon players as they explore perspectives apart from their own opens doors unavailable within non-participatory media like films and books. For internal struggles like mental illness especially, the possibilities of first-person interaction to help others understand these amorphous illnesses is immense. The intimate sensibility of existing through the experience of others initially perceived as unlike oneself and making decisions from their unfamiliar perspectives personalizes the perception of mental struggle.
Depression Quest exemplifies this ethos. This text-based adventure developed by Zoë Quinn and written with assistance from Patrick Lindsey — both of whom themselves dealt with clinical depression — is the progenitor of what remains the largely untapped field discussed in this paper. The game consists of a handful of text boxes, each about the length of a novel’s page. Each page presents another time-fragmented day in the character’s life as they navigate familiar circumstances: struggling relationship dynamics (romantic, platonic, and familial), a soul-sucking day job, and the existential passing of time. Any adult can find these experiences relatable, allowing them to form a compassionate bond with the character in spite of behaviors they might not understand. Put otherwise, this compassionate bond is the fertile ground upon which they can begin to understand why living with depression is a challenge.
However, the true genius of Depression Quest is its genre-flipping gimmick: taking away choices from the player (where players would usually expect choices to be added). As the player’s choices and the general whims of depression shape the trajectory of the character’s mental state, red lines cross out what would seem like the logical courses of action to neurotypical individuals. This mechanic thus forces a neurotypical player to make choices that may not seem optimal or “the best” while simultaneously signaling to neurodivergent players that they are not alone in their inner struggle. So, this line-striking constitutes both the ultimate interactive teaching mechanism and a substantive method of neurodivergent representation. In combination with the aforementioned deft writing that captures the Millennial experience (at the time only one recession deep), Depression Quest achieves its mission statement.
But does Depression Quest’s goal of teaching neurodivergent players about the amorphous experience of depression hold up in practice? Anecdotes are abundant but I can provide one of both my own and my father, an experience that set me down the road of studying this topic around the time of the game’s 2013 release.
My experiences with bipolar and anxiety have shaped the trajectory of my life, especially in the last decade of my adulthood. Those in my orbit have had difficulties understanding the impacts of my mental health issues, causing strife in many of my relationships. Why was I so often unable to complete what seemed like simple tasks? Why were social outings an often-unbearable challenge for me? What was the point of intensive therapy? My father Jim Rattray was looking for these answers, and after playing Depression Quest, his view of my struggle with mental illness was forever altered. In his words:
There’s a gargantuan chasm between observing and experiencing, between watching and doing. I’m the parent of a son who has suffered from mental illness, namely depression and anxiety, from adolescence through adulthood. It’s not a passing affliction, it’s a lifelong struggle. While I believe us to be extremely close, I have watched from what seems a very distant and often detached perch as he attempts to navigate something that is simultaneously silent and screaming, something you cannot see but is in your face all day, every day. Watching leaves you helpless.
Through Depression Quest, for a brief moment, I finally walked in my son’s shoes — and opened my own eyes. It helped me better understand what he’s experiencing and how my actions might help or hinder. It’s made me a better, more patient parent and probably a better human being. And most of all it showed me that no matter how much I try, I can never experience what he’s experiencing. But now I can listen in a way that might bring us closer to a shared understanding and path forward. It’s given me hope.[2]
Critical to my father’s experience is an understanding of Depression Quest’s role as a simulation; there is simply no substitute for an actual lived experience. Yet what Depression Quest offered was an authentic facsimile that allowed him to step into “my” shoes, make “my” actions, and see the consequences of his own player agency. It left him with a newfound mutual understanding that I saw the ramifications of personally. It facilitated a stronger father-son bond.
This experience reinforces the core concept about the power of interactivity as a teaching mechanism: being is believing. While seeing depictions of mental illness in non-participatory mediums can give us an external view of a character’s struggle, mental illness is, well, mental. It is an internal struggle understandably ambiguous to neurotypical individuals. Games and other methods of interactivity allow us to take on that critical viewpoint. As my father noted, “‘Experiencing’ depression, even through a simulation, showed me where depression can originate, how it can worm its way into what seems like it should be the most benign aspects of daily life, how it can derail someone in the snap of a finger.”[3]
From my own perspective, playing Depression Quest in 2013 was also a pivotal experience. At its time of release, I was struggling with depressive episodes I did not understand well nor was I medicated for. This made me unable to finish college at the time because of a general inability to function. Depression Quest’s depiction of a character who also struggled with simple functioning, written by people who dealt with the condition themselves, helped me understand myself a bit better. It reaffirmed that what I was going through was in no way “wrong” no matter how much societal expectations made it out to be so. This authenticity also gave a validity to my father’s Depression Quest experience in my mind.
All this impact from some authentic prose and a simple gimmick that manipulates player agency. If this is what games at their most bare bones can accomplish, the possibilities are truly endless.
The games discussed in this paper will be more complex than Depression Quest and showcase a myriad of modes of play that are effective at teaching about mental illness. Quinn’s acclaimed text-based adventure laid the groundwork for these titles to thrive.
Part 2 — Curbing Stigma
While mental illnesses take innumerable forms, many share one constant: a history of stigmatization. While an in-depth discussion of this history is beyond the scope of this paper, it is worth discussing a few ways in which stigma can be directly curbed through play.
Negative school climates have shown to be one of the most critical places where high stigmatization of mental illness and low depression literacy are bred.[4] However, there are signs that improvements are being made in high schools with the implementation of play into mental health awareness programs. In a 2020 study, Youth Aware of Mental Health (YAM) found that through a mix of “interactive lectures” and role-play sessions in their school-integrated program for adolescents, stigma was reduced amongst a majority of students, which in turn increased their probability to seek help.[5] YAM’s website touts their role-play initiative in particular which has a holistic focus of building a support network between peers.[6] For many of these teenagers, YAM’s programs may be their first experience interfacing with psychiatric therapy so this emphasis on engaging with peers humanizes mental illness through associations with familiar faces. Further, YAM understands that playing roles — just as one does in Depression Quest — allows students to come to their own realizations about mental illness that lectures do not always facilitate. If we consider that video content has been found to be more impactful than lectures on teaching about mental illness, we can extrapolate that the even more sensory experience of play could push this impact further.[7]
It could be argued that the YAM’s initiative is successful because of its in-person nature. However, in an ever more online world and a psychiatric industry forever changed by COVID-19 lockdown adaptations, it is important to meet audiences where they are. Acting Provost and Vice President of Academic Affairs at Hunter College CUNY, Dr. Manoj Pardasani states,
For younger generations like teenagers and adolescents, they’ve grown up texting, they prefer that. Do I think that’s the best way to get treatment? Maybe in my opinion not, but I’m actually excited that people are at least seeking that help and maybe that chat then leads to an in-person meeting or a Zoom meeting.[8]
Dr. Pardasani notes how mental health games could be established online and later introduce an in-person variant, or vice versa.
To this end, Dr. Pardasani co-authored a study on how effectively Age-Tastic! — a board game-like health and wellness program for older adults — is able to teach its demographic about depression. They found that through playing Age-Tastic!, older adults’ responses to questions regarding the nature of mental illness favored more factually accurate answers. Of particular note is the statement, “only weak people suffer from depression” which tallied an agreement score of 54.5% before the study but only 2.4% afterward, which is to say Age-Tastic! meaningfully counteracted mental health stigma in these older adults.[9]
But why did these older adults hold this stigma to begin with? The answer lies in a crude but illuminating comparison between mental illnesses and visible illnesses such as cancer or pneumonia. With cancer, the associated physical deterioration and often fatal ends are well-known. Our instinctual fear of death makes the illness feel emotionally simple to wrap our head around, even if cancer is anything but emotionally simple. Mental illnesses typically do not show themselves in such obvious ways. While there are many external symptoms — the least of which are weight gain or loss, inability to keep up with one’s daily tasks, and in the worst cases suicide — they have typically been stigmatized as a fault of the patient. We cannot see the mental distortions that cause these external signs to occur, and so stigma is born. As Dr. Pardasani adds:
The other challenge is that for most physical illnesses there’s actually a test. If you have cancer, you’re going to get a biopsy that shows you have cancer. If you have HIV/AIDS, there’s a blood test that’s going to show your viral load. If you have pneumonia, there’s an x-ray that shows you have pneumonia. But there’s no medical test that conclusively shows you have a mental disorder. This creates that subjectivity of “what am I going through” because it’s unique to every individual. Depression in five different people manifests in five different ways, so how do you address it?[10]
Currently there is no one answer to this question, but as we will see, many of the games covered in this paper will not directly specify the mental illness being depicted for this reason. These games strive to disassemble stigma surrounding neurodivergence rather than putting the focus on teaching facts. While the depiction of mental illness should be rooted in factuality, the most important message to impart upon players is that everyone is human.
Note that an illness like cancer is well-portrayed in a passive medium as the neurotypical perspective is more likely to emotionally understand its fatalistic element and can tie visible physical impacts directly to these illnesses. Interactive media is therefore specifically well-suited to exploring the fatalistic elements a neurodivergent individual may feel, or whatever shape their internal struggle takes. The tendency for passive mediums to present neurodivergent characters as “others” in an attempt to express their mental struggles has often served to amplify stigma. In active mediums, even when a character is portrayed as an “other,” players are given the opportunity to explore their inward perspective through “being” them.
However, by the same token that makes interactivity powerful for exploring mental illness, using it improperly can have equally powerful negative impacts. We will grapple with this in the following section.
Part 3: The Impact of Poor Representation
It may seem counter-intuitive to precede a discussion of games that have successfully elicited the experience of living with mental illness with those that have not. However, understanding the negative power of poor representation is critical context for understanding the power of interactivity at its best.
When you type “depression” into the search bar of Steam (the leading PC digital game storefront), the first result you’ll find is Depression Quest. Below it resides Depression The Game. However Steam may be tabulating its search results, these are the most prominently presented games titularly about depression on the platform. Unfortunately, the gulf between how the two present depression could not be more vast.
Depression The Game sees the player embodying a 23-year-old male as he circles around his house, completing a handful of menial daily tasks as he trudges through a loop of rooms.[11] It is a concept that in other contexts may effectively communicate the sense of feeling stuck in a depressive low. However, Depression The Game fails to capitalize on this narrative device by failing to humanize its character to neurotypical players and presenting content that may trigger neurodivergent players, particularly in its ill-conceived depiction of suicide.
One of the narrative choices that makes Depression Quest work is that it does not broach its character’s suicidal ideation. While suicide is undeniably at the core of discourse on mental illness, it causes many neurotypical players to instantly disconnect given suicide’s heavy stigma. While it is possible to depict suicide in capacities that can have a positive impact in the reduction of stigma, audiences are going to elicit an inherently more polarized response than they would to the commonly experienced relationship and vocational woes of Depression Quest.[12] It is thus to Depression The Game’s deficit that the entire characterization of its player character revolves around his thoughts of self-harm. As the character vaguely opines about their self-hatred and wish to take their life, the player is constantly surrounded by notes on the wall sharing similarly brooding sentiments and real images of slit wrists hung in his bedroom (the first thing the player sees upon starting the game). Without providing any meaningful background about the character, the player can only define him by his depression, an illness that the game erroneously defines as a want to harm oneself out of self-hate. Further, in the game’s “bad ending” that occurs if you choose to commit suicide, the character sits on the couch and watches clips of guns in mouths on the TV as the screen slowly fades to black. There is a soft glorification of suicidal acts as the character vocalizes how they are making the right choice with no counterpoint or pushback provided by the developers. Someone suffering from depression who may come across this game given its prominence in Steam’s search function could have their own ideation reaffirmed by such an ending rather than being led to an understanding that suicide is an awful way to go.
It should be noted that these missteps are not due to malintent. Players are smartly provided with a suicide hotline number before playing, something that should be included as part of any game tackling this sensitive subject matter. Also, the game’s store page description includes a note regarding how the game is based on the developer’s own struggle with depression, stating his goal is to create discourse around mental illness.[13]His game is thus framed as a reflection of his own thoughts. Yet while these thoughts may indeed be authentic, this unfiltered approach serves to facilitate the aforementioned negative potentialities.
This is not to say authenticity is unimportant. Both Quinn and Lindsey note upfront their own struggles with depression and their attempts to pull from many diverse experiences of the illness beyond their own to craft Depression Quest’s story. But authenticity must in equal measure come alongside omission, especially when it comes to topics like mental illness. A good measure of this are the guidelines set for journalistic reporting on suicide which advise against “describing or depicting the method and location of the suicide” and all forms of glorification.[14]
As said by video essayist Timothy Hickson while discussing The Suicide of Rachel Foster, a game in which the player acts out a character’s suicide plan, “In other media forms, though you may understand a character’s motivation to suicide, there’s a visual and psychological distance between you and them. But you are not watching someone else here. Player agency means that these actions feel like your own, these hands feel like yours.”[15] While this may be an authentic depiction of suicide insomuch as it describes its often-planned nature, it can inadvertently teach vulnerable players how to make their own plan. It is not unlikely that these individuals would find themselves playing a game about their ideation and as such, extra care must be given to representing mental illness. Plus, showing how to create and execute a suicide plan through play can make the act seem entertaining, risking dangerous Pavlovian conditioning.
It must be noted that there is no scientific evidence to link the playing of video games to suicide, nor is suicide often the result of a single factor.[16] Still, it is important that game creators (and creators of any media) be careful to make sure they do not represent mental illness in capacities that have the potential to cause harm. Though, this is not to say that suicide is a topic that cannot be broached appropriately as we will explore in the following section.
Part 4: How A Finch Evolved Mental Illness Representation
While the games covered thus far have focused solely on depicting mental illness, that is not the case for What Remains of Edith Finch. This acclaimed adventure game involves a series of abstract fantasy sequences depicting how each member of the fictional and eccentric multi-generational Finch family passed away. While there is coding of potential mental illness in multiple of these stories, only one outright addresses the topic: that of Lewis Finch, 21, salmon cannery worker.[17]
While Lewis’ illness is unspecified, we know from his psychiatrist’s narration that in the process of recovering from alcoholism he became tightly gripped by occupational ennui. Lewis began daydreaming of an idealistic fantasy world, ever expanding as he disconnected from his harsh reality. It is a setup that hits many of the same woes about being a cog in a capitalist machine than Depression Quest’s does, albeit with more specificity in Lewis’ circumstances but abstraction in those circumstances’ depiction. It is likely that many adult players have also held a job that felt like a monotonous trudge, so mindless that their mind could not help but wander to a favorable unreality. Lewis’ situation thus makes both logical and emotional sense, breeding enough empathy in the player that when he gives himself entirely over to this fantasy world, we are already in his camp.
This bonding also works because the game’s play is engineered to mimic the duality of Lewis’ ennui and wonderment. With the right analog stick of a game controller, the player controls Lewis’ right hand as he pushes an endless stream of salmon into a beheader, one by one. The player continues this action for the near entirety of the 10-minute segment, simultaneously monotonous and hypnotizing. Meanwhile, the left stick is dedicated to navigating a fictional King Lewis through his daydream as he emerges from a dungeon and journeys to his kingdom. Juxtaposing controlling the “fun” of the daydream and the “boring” of salmon beheading emphasizes empathy toward the former. This helps ensure the player remains empathetic with Lewis as they too prefer the “fun” world to first-hand repetitive busywork.
The sequence ends with the daydreamt King Lewis bursting into the dour cannery, at which point the daydream that began in a small thought bubble overtakes the entire screen. Fish beheading ceases, and when we walk past Lewis at his workstation, we can see him transfixed in the salmon-beheading motions without any salmon left to chop. From here, the player rides the salmon conveyer belt up to a door pouring over with light. Beyond the door, King Lewis makes his way past throngs of colorful subjects celebrating his big moment and finally to his queen, awaiting him with a crown for kingship. He kneels to be crowned under a guillotine, the screen cuts to black, and we hear the same sound effect of the blade dropping that played countless times before while beheading salmon. The implication is obvious, and the game says no more beyond Edith noting how Lewis was a “really cool” brother.
Lewis’ suicide is a gut punch. We know to expect it as the premise of the game sees every Finch’s life coming to end in a myriad of esoteric capacities, yet Lewis seems more grounded despite suicide’s stigma. The tight grip of capitalism that sucked away at his will to live is based on a stark reality where mental illness need not even apply.[18] His psychiatrist nor Edith ever refers to Lewis in a derogatory or pejorative manner, instead spotlighting his creativity that players see unfold before their eyes. And you’re not left guessing as to his method of death, making it feel far more tangible than the question marks around many of his family members’. The focus on whimsy over the non-abstracted realism of Depression The Game evokes both a truer authenticity and a more responsible depiction of suicide. As put by Hickson, “What Remains of Edith Finchdoesn’t really do any of the stereotypically realistic things. This is not what suicide, depression, or hallucinations usually look like at all. But perhaps more than any other game, What Remains of Edith Finchmore empathetically captures what suicidal ideation feels like.”[19]
Counterpoints have been made to this claim, seeing his disconnect from reality and into a fantasy world as continuing tropes regarding “ineffectual attempt[s] at recovery,” though it is unclear the exact nature of the tropes being referred to by this author.[20] The celebratory nature of Lewis’ final scene could also be described as glorifying the concept of suicide. It is true that by not addressing the topic further, the game runs the risk of not properly expressing that Lewis’ way out was not ideal or idealistic. However, the game gives a clear impression of the pain that Lewis’ passing had on his family and psychiatrist. Lastly, unlike other games discussed in this paper, there is a specific lack of player agency in What Remains of Edith Finch, giving a sense of inevitability to the deaths of its characters. This is a powerful narrative technique for most of the game’s vignettes as it provides a sense of unavoidable dread. However, it can present issues when paired with sensitive topics such as suicide due to its possibility of pushing notions that suicide is an inevitability. Perhaps other literature could have been included in the game to explain the nature of Lewis’ suicidal ideation.
Even with these critiques, the Lewis Finch sequence remains a marquee example of how to teach about the experience of dealing with a mental illness. It presents the character free of pejoratives or derogatory language, forms bonds with players based on socioeconomic experiences and ludic activities, and typically makes choices in-line with previously discussed guidelines when choosing how to portray Lewis’ suicide.
Part 5: Battling with Emotions
Many who have played games for some length of time will have a frame of reference for the construct of its many genres. Recontextualizing and subverting this knowledge is a potent means of using familiarity to teach. Omori — a game about how neurotypical and neurodivergent characters deal with trauma in individually divergent ways — is particularly adept at genre recontextualizing, a core example being its emotion-based battle system.[21]
Traditional Japanese Role-Playing Game (JRPG) battle systems involve an abstraction of combat born from hardware limitations in the 1980s and 1990s, as well as a lineage of tabletop games. They typically boil down to some variation of players inputting commands through menus, their units executing the commands, computer-controlled enemies taking a turn to retaliate, repeat. Many larger franchises moved toward real-time combat as increasingly powerful hardware allowed them to forgo this abstracted depiction of fighting. This shift meant those who loved the traditional turn-based tactical style grew nostalgic for what the industry appeared to be abandoning. Smaller projects leaned into these systems due to budget constraints, conveniently filling this nostalgia void. The expectations of players familiar with turn-based combat allowed these developers to subvert the formula to derive new meaning, something achieved to notable success in Undertale where players can choose to use the battle system to talk down enemies’ aggression rather than damaging them.
Omori follows this lineage. Specifically, it re-envisions the mechanic of status effects — inflictions that give or take away character power — as emotional states. In standard combat, these boil down to happy, angry, and sad, changing character attributes to thematically match each. “Angry” increases a character’s attack but lowers their defense, simulating reckless behavior. “Sad” increases the character’s defense as if they put up walls around themselves, but in turn this decreases their speed and causes damage taken to their health to also deplete their energy (used for special attacks). This simulates the difficulty of everyday tasks as shown through Depression Quest (as well as ASD and Conversations on the Spectrum as discussed in the next section), and aptly a character that is inflicted with more sadness can become “depressed.” “Happy” ultimately serves as a mirror opposite of the other afflictions, with the positive attitude resulting in increased speed and a higher chance to do greater damage. Each of these can be powered up to a more intense version of the emotion.
The status effects themselves are nothing new to the genre; it has been a staple since the earliest entries. But that is what makes the emotion theming all the more potent. Pre-existing knowledge of how things usually are becomes a platform for informing through a new context. The benefits of reaching emotional states coded in mental health terminology such as “manic,” “depressed,” and “enraged” causes players to associate these concepts positively with strength in battle. It may be reductive to paint depression as more sad than sad or manic as more happy than happy, but to a neurotypical player who does not have that lived experience, it is a strong starting point which the game’s narrative expands upon or can be the basis for further learning elsewhere.
Perhaps most critical is how representation-focused narrative design separates the main character Omori from his friends with his unique ability to reach a third level of each emotion. Omori is a silent, unemotive protagonist throughout the game due to his struggle with trauma and other unspecified mental illnesses, heavily implied to be depression and anxiety in the game’s content warning (though the emotions system may also code him for bipolar). Approximately four years of him entering a hikikomori state after suffering trauma has left him socially maladjusted in the game’s real world, making his headspace where most combat takes place a reflection of his personality. Here, his inability to control the extremes of his emotions in battle turns into his superpower. He — and by extension the player — benefit from this increased strength, making him the linchpin of combat strategies. So, while neurotypical players may have trouble connecting with Omori monotone nature compared to his highly emotive friends, his empowered ability in combat frames his challenges positively, engendering empathy in the player based on what they mechanically gain. The ensuing acceptance of his clear “otherness” (which typically is best avoided in representing mental illness, though works here) may not make him relatable to neurotypical players but does allow them to have an emotional understanding of his darker moments punctuated by disturbing psychological horror sequences.
Omori’s heightened emotional capacity in his headspace also serves to give players a better understanding of him in the real world where he is known by his real name Sunny. Sunny cannot go beyond basic emotions or become happy at all as is more characteristic of depression. Going from “superhero” Omori to Sunny’s more realistic struggle with depression emphasizes the debilitating qualities of the latter. The juxtaposition positions depression as a harsh reality and paired with story beats, players are led to sympathize with the challenges presented by mental illness that are holding Omori back. Also important is that due to significantly fewer and less complex battles in the real world, the adverse impact his illness has on gameplay does not feel like it is holding back the player’s progression.
Omori also uses its battle system in subversive capacities that simulate a neurodivergent experience. At multiple junctures, the game puts Sunny in situations against eldritch horrors that represent mental blockades put up to shield traumatic memories. With Sunny in the “afraid” emotional state unique to these fights, his attempts to physically attack the monsters does nothing. Instead, he must use skills such as “calm down,” “focus,” and “persist” at the correct moments to overcome mental obstacles by composing himself. This culminates in a final battle against his Omori alter ego in which all the non-combat CBT/DBT[22] skills he has learned over the course of previous battles are used in conjunction to win through self-acceptance. This subversion of what “combat” is, forces players to think about fights from a new perspective of healing oneself rather than hurting others. For neurodivergent players, techniques like deep breathing can also be applied to their own lives, though it is not likely Omori’s intent to teach such methods.
This emotion-based battle system is only a fraction of what makes Omori such an effective addition to the discourse on mental illness. Its narrative about how the cast of characters — both neurotypical and neurodivergent — have dealt with a shared traumatic event in different capacities allows for a swath of perspectives to be platformed. Allowing every player to find their own way to relate to the game through this diverse cast makes its message more accessible than games that only offer one perspective. This is something that developers of future games about mental illness should consider where appropriate.
Part 6: Climbing the Mountain
Much ink has been spilled about Celeste, the critically acclaimed platformer that uses the metaphor of climbing a mountain to represent coping and self-acceptance.[23] The journey sees Madeline grapple with her anxiety and depression as a physical manifestation of her mental illnesses meddles with her ascent. She learns to cope with panic attacks by balancing a floating feather mentally (a minigame) and stumbles her way through interpersonal relationships with people she meets along the way. She is also noted to be transgender by creator Maddy Thorson — herself transgender — and while this was not intended at game launch, Thorson later realized during her own transition coinciding with Celeste’s development that she was speaking through Madeline.[24] Thus, Madeline’s climb can also be viewed through this lens. The many layers to Madeline make her journey one of self-discovery foremost, and mental health is but a part of that; people are free to relate to her on whatever their own terms might be, and other understandings can follow.
But what defines Celeste’s for most players is its difficulty. This game requires significant motor skills from the player as they traverse ever more punishing levels. As a work of narrative design this is key to selling the trials and tribulations of Madeline. As put by writer Jeff Ramos, “As I get farther in Celeste, I feel more emboldened in real life — just like Madeline does as she quests up the mountain.”[25] As her journey gets emotionally tougher, so too does the player’s. To the player, her victories start to feel like their own. Given former research that has shown an inability to perform ludic activities can cause depressive feelings, we can extrapolate that the player’s losses simulate Madeline’s lows.[26] Players feel a sense of stakes in her stumbles, even if they have no agency over them (most are shown through cutscenes). And by the time you have reached the peak, you have come to understand Madeline because you have been emotionally in-sync with her throughout the journey.
It needs to be emphasized that Celeste is an incredibly difficult game. However, those who truly cannot progress are importantly not left behind as Thorson included accessibility options that allow the player to fine-tune the difficulty to their skill level. As relayed to me by Mark Brown of popular game design YouTube channel Game Maker’s Toolkit:
Difficulty is subjective. If Celeste is supposed to be, say, “a difficult challenge to overcome,” what’s difficult to one player may be unbearably challenging, or nearly impossible to another. Options allow players to find a level of difficulty that is suitable for their needs. [However,] the game uses language and communication to clearly state to the player that assist mode is not the intended way. This should leave players in no doubt that they may be “spoiling” or changing the intended experience.[27]
To this latter point, Brown mentions in a video on accessibility features that unlike similar games like Cuphead, the assist mode in Celeste allows the player to experience everything in the game.[28] Some neurodivergent players may also fall into the category of those who find these accessibility features necessary to complete Celeste, meaning it allows them to feel represented both in the narrative and the options. While the narrative loses its aforementioned intended qualities designed around difficulty, it is more important that the overarching message can find a broad audience in whatever capacities possible. This consideration is one unique to interactive media and one many games fail to include to the detriment of reaching wider demographics.
A developer who uses difficulty as a means of expressing the autistic experience through play is NYU Game Center alumni Sarah Doherty Granoff. While Granoff notes that games are not a replacement for a lived experience, she uses them to convey her message due to their “unique capacity for empathy.”[29],[30]
In Granoff’s game ASD (autism spectrum disorder), the player character’s train malfunctions, forcing her to walk through unfamiliar territory to reach her school. This discomfort is bolstered by the presence of unpleasant people (smokers and catcallers) who cause her energy to deplete, while tactile interactions with items on the ground, stops at coffee shops, and positive interactions refill her energy. Successfully navigating through the game requires weaving between discomforts littering the street while picking up items and making the right decisions at multiple junctures — not always intuitive to neurotypical players — to maintain stamina.[31]What is important about ASD as a teaching mechanism is that its discomforts are those that neurotypical players would likely share, a familiarity that fosters empathy for how they’d present a challenge to those living with autism. Those living with autism have a different reaction to stimuli from those who are neurotypical, but the discomforts are shared.
Granoff’s game Conversations on the Spectrum takes a similar approach, in this instance simulating the stresses that come from small talk.[32] The player uses their mouse to simultaneously maintain eye contact, choose correct reactions to incoming dialogue, and spin a fidget spinner to relieve stress. Balancing all these factors while managing two meters for eye contact and stress is particularly challenging for many players, inducing a stress akin to what Granoff feels. However, unlike ASD, her intentions were not to make Conversations on the Spectrum difficult; rather, she found that in authentically expressing her experience through the game it came across as difficult to others. To this, Granoff said, “When my classmates were playing it, their reaction to it was consistently like, “Oh my god, this is so hard.” And I was sitting there thinking, “Really? I don’t think it is that difficult.” Then I realized, oh wait, I made the game, of course I know how to beat it, but also this is my everyday life.”[33]
Unlike Celeste, there are no options to ease the difficulty of Granoff’s games. However, given that they align more with serious games (a game made for purposes other than entertainment) than consumer products, this discrepancy is acceptable.[34] While Celeste’s foremost concern is the enjoyability of its gameplay, ASD and Conversations on the Spectrum are more akin to simulations that eschew fun for meaning. Both approaches have an important place in this discourse, and while a deep dive into the topic is beyond the scope of this paper, serious games have the potential to aid in educational settings and the psychiatric treatment of those dealing with mental illness.[35],[36],[37]
Part 7: Seeing Oneself
While teaching audiences about mental illness through play has been the focus of this paper, it is also important to highlight how games can allow neurodivergent players to see themselves amidst a neurotypical gaming landscape. These are just a few examples in addition to those already covered in this paper.
Granoff recounted two experiences of seeing autism represented in games. First was the Overwatch playable character Symmetra who was revealed in a May 2016 comic to be autistic.[38] This was reaffirmed in March 2017 by then-game director Jeff Kaplan in a personal letter uploaded by its recipient.[39] In September 2022, narrative designer Joshi Zhang outlined on Twitter the ways in which Symmetra’s autism is specifically portrayed in Overwatch’s gameplay, including voice lines where she comments on sensations that provide her comfort and discomfort, and through various forms of animations.[40] Granoff also noted elements such as her role as a “control character” is indicative of her “desire for order and routine and structure,” and Overwatchdeveloper Blizzard Entertainment’s careful manner in expressing her autistic traits through nuance.[41] This has a normalizing effect as Symmetra does not feel mechanically impaired compared to other characters, and her autistic traits are most likely to be noticed by people living or aware of the autistic experience. Put otherwise, those who matter most feel seen.
However, Overwatch is a rarity in the mainstream gaming space given that a stark few have specifically indicated characters to live with autism. This gap in representation forces autistic players wanting to see themselves reflected to seek out characters coded with such traits, even if such characters are described by the game or developers as neurotypical. Granoff called this process “headcannoning” in discussing how she saw herself through autistic coding in Control’s playable character Jesse Faden.[42] According to Granoff:
One of the things I appreciate most about viewing Jesse Faden as autistic is that the game isn’t explicitly about that, and at the same time what I interpret as reflections of her being autistic are manifested in the game design, in the sound design, in the map design. It ends up striking a perfect balance where it does reflect itself in the game but is not Jesse Faden against her autism. This is just a reality of who she is.[43]
A personal anecdote of finding representation in an interactive environment is the anonymous letter-sending software Kind Words. While not a game per-se (the functionality is writing letters to people’s requests for advice, and asking for advice yourself), gamification elements such as collectable stamps give a tangible reward that you can show off to others. Help more people, get more rewards. During the 2020 COVID lockdown, this served as a low-stakes capacity for me to speak about the mental turmoil of being alone in a small apartment and know I was being heard, as well as therapeutically help others dealing issues often similar.[44] While toxicity is a concern in such an environment, I encountered none as response letters are a one-way street and there are no personal identifiers. People only know the information you choose to divulge, and divulging personal information is prohibited. The platform also creates a soothing and customizable atmosphere to best fit each player’s needs. While not a representation of mental illness on its own, Kind Wordsis a safe space for mental illness to be represented and acknowledged by users.
This said, while representation is important, it is also important to make sure that someone with a lived experience of what’s being represented has a role in crafting it. While much praise has been heaped upon Hellblade: Senua’s Sacrifice’s representation of a character struggling with psychosis, others have noted that its developers made missteps in allowing speaking to medical professionals to stand in for working with someone with a lived experience of psychosis. One such risk of this approach is the potential to depict what’s being represented (in this case, psychosis) as a monolith. Dr. Pardasani’s statements regarding the individualistic nature of mental illness ring true here. And as writer Dia Lacina puts it:
There’s a saying in the autistic community: ‘If you’ve met one person with autism, then you’ve met one person with autism.’ This could also be said of mental illness. Despite 60-plus years of attempted codification by the American Psychiatric Association, no two experiences are exactly alike, even within single diagnoses or symptom sets. While Hellblade attempts to locate its depiction of mental illness wholly within Senua, she isn’t a person. Senua’s a gamified symptom set; a collection of harvested delusions turned into set pieces and a backstory sketched out exclusively by her relationship to her parents, a mystical Captain Jack Sparrow and a thoughtless boyfriend. She’s a case where “getting it right” took precedence over making it real.[45]
These challenges are difficult given the sensitive, nuanced, and individualistic nature of mental illness. It is a hurdle not unique to this subject. Games about social issues have been grappling with proper representation for some time. The step-into-another’s-shoes experience games can offer require a higher degree of accuracy in representation, something that can only be made sure of if someone with a lived experience has direct involvement. For every Symmetra you have many Jesses who are only coded as autistic, or Senuas whose authenticity is called into question. We will next explore how developers can enhance their future games to better serve everyone.
Part 8: A Better Magic Circle
In their widely taught textbook Rules of Play, Katie Salen and Eric Zimmerman employ the term “magic circle” to represent the invisible boundary a player enters when engaging with a game.[46] Understood notions of what objects indicate change (for example, a coin can become a board game piece), and a new set of rules are imposed.
The games we have covered are each their own magic circle within which the player is asked to perceive a different reality and play by its rules, and in turn learn something about others or themselves. In Depression Quest, the rule that dialogue options will be taken away from you is accepted, allowing the player to experience a sensation of living with depression. In Lewis Finch’s sequence in What Remains of Edith Finch, the player accepts a lack of agency despite knowing that every sequence ends with a Finch’s death. In Omori, players accept emotions to be status effects, and so forth.
Why it is important to discuss the magic circle is to understand how it can be punctured. Should developers want to tie their fictional lessons to the real world, overt cultural norms must have a place within the magic circle. Salen and Zimmerman describe this by noting, “Considered as culture, games are extremely open systems … the focus is on the way that the game exchanges meaning with culture at large.” They note as an example how American Football teams
are being opened up to sociopolitical discourse surrounding Native American mascots.[47] So too could games about mental illness more directly integrate real-world discourse into their play, something that would help better represent the mental illness experiences of characters while making it clear that real people experience these same things. Brown provided a few examples of how games do this to highlight sociopolitical and socioeconomic inequalities:
In Mafia 3, police officers respond to crimes more quickly in white neighborhoods, than black. And in Dragon Age Inquisition, there is a level set in a ball, and the player has to be aware of their court approval stat — this stat has a different starting level depending on what race you’re playing as. A final example is Papers, Please, which shows first-hand how corruption can happen, by putting the player in a difficult financial situation and offering ways to make money illegally.[48]
Imagine if in similar stride Omori’s emotions system had an actual impact on the state of characters outside of battle that made it easier or harder to complete tasks, or if Celeste included more direct ways for Madeline to signal her changing inner-monologue congruent with how many times a player must retry a level? Or if Depression Quest made clearer why dialogue choices are being made unavailable based on your prior choices? (Depression Quest features a few indicators of your character’s depression level but more clarity could only enhance its teaching abilities.) While these exact suggestions might or might not be the right fit for these games, the point is that in addition to expanded representation, cultural puncture of the magic circle is an important way in which games about mental illness can connect their messages to the real-world. In other words, it would allow games to become better teachers about mental illness.
The more ways that developers find to open up their magic circles — as well as real-life development circles to those living with depicted conditions — the more authentic and informative representation will become. That the games in this paper are all from the last decade means that this is an ever-growing but still nascent aspect of the games industry. Given an increased understanding particularly by independent developers regarding how to convey their lived experiences through games, there is hope that the next decade could boom with more games that help the public better understand mental illness. We’d all be better for it as being is believing.
[1] Zoë Quinn, Depression Quest, The Quinnspiracy, PC/Mac, February 14, 2013.
[2] Jim Rattray, interview by author, New York, November 22, 2022.
[3] Jim Rattray, interview by author, New York, November 22, 2022.
[4] Lisa Townsend et al., “The Association of School Climate, Depression Literacy, and Mental Health Stigma Among High School Students,” Journal of School Health 87, no. 8 (August 2017): 567–574.
[5] Janet C. Lindow et al., “The Youth Aware of Mental Health Intervention: Impact on Help Seeking, Mental Health Knowledge, and Stigma in U.S. Adolescents,” Journal of Adolescent Health 67 (2020): 101–107.
[6] “About YAM,” Youth Aware of Mental Health, https://www.y-a-m.org.
[7] Kim et al., “Comparison of the Effects between video-based contact and educational lecture on the stigma of mental illness,” European Neuropsychopharmacology 19, supplement 3 (September 2009): S484.
[8] Manoj Pardasani, interview by author, New York, November 4, 2022.
[9] Jacquelin Berman, Manoj Pardasani, and Mebane Powell, “The impact of Age-Tastic! On health literacy about depression among older adults: a pilot study,” Educational Gerontology 46, no. 3 (2020): 117–128.
[10] Manoj Pardasani, interview by author, New York, November 4, 2022.
[11] DeepWorks Studios, Depression The Game, DeepWorks Studio, PC, July 2018.
[12] Mark Sinyor, Steven Stack, and Thomas Niederkrotenthaler, “What the highest rated movie of all time may teach us about portraying suicide in film,” Australian & New Zealand Journal of Psychiatry 54, no. 3 (2020): 223–224.
[13] “Depression The Game,” Steam, July 2018, https://store.steampowered.com/app/881920/Depression_The_Game/.
[14] “Best Practices and Recommendations for Reporting on Suicide,” Reporting on Suicide, https://reportingonsuicide.org/recommendations/.
[15] Tim Hickson, “On Writing: Mental Illness in Video Games | a video essay,” Hello Future Me, April 3, 2020, educational video, https://www.youtube.com/watch?v=SQCb7GiNOrE.
[16] Peter J. Etchells et al., “Researchers should avoid casually attributing suicide to video game play as a single factor,” Perspectives in Psychiatric Care 58 (2022): 880–882.
[17] Giant Sparrow, What Remains of Edith Finch, Annapurna Interactive, multi-platform, April 25, 2017.
[18] Sarah Waters, “A Capitalism That Kills: Workplace Suicides at France Télécom,” French Politics, Culture & Society 32, no. 3 (Winter 2014): 121–141.
[19] Tim Hickson, “On Writing: Mental Illness in Video Games | a video essay,” Hello Future Me, April 3, 2020, educational video, https://www.youtube.com/watch?v=SQCb7GiNOrE.
[20] Sky LaRell Anderson, “Portraying Mental Illness in Video Games: Exploratory Case Studies for Improving Interactive Depictions,” The Journal of the Canadian Game Studies Association 13, no. 21 (2020): 20–33.
[21] OMOcat LLC, Omori, OMOcat LLC, multi-platform, December 25, 2020.
[22] Cognitive Behavioral Therapy (CBT) & Dialectic Behavior Therapy (DBT) are psychological treatments for mental illness.
[23] Maddy Makes Games, Celeste, Maddy Makes Games, multi-platform, January 25, 2018.
[24] Maddy Thorson, “Is Madeline Canonically Trans?,” Medium, November 6, 2020, https://maddythorson.medium.com/is-madeline-canonically-trans-4277ece02e40.
[25] Jeff Ramos, “Celeste stresses me out, and that calms me down,” Polygon, February 8, 2018, https://www.polygon.com/2018/2/8/16961386/celeste-stress.
[26] Cecilia Garell, “Health games — healthy in what way?,” University of Gothenburg, Paper 131 (September 2015).
[27] Mark Brown, interview by author, New York, November 25, 2022.
[28] Mark Brown, “What Makes Celeste’s Assist Mode Special,” Game Maker’s Toolkit, educational video, February 21, 2018, https://www.youtube.com/watch?v=NInNVEHj_G4.
[29] Sarah Doherty Granoff, interview by author, New York, November 13, 2022.
[30] Sarah Doherty Granoff, “ASD,” itch.io, 2017, https://octopi-with-hats.itch.io/asd.
[31] Sarah Doherty Granoff, ASD, Octopi With Hats, PC/Mac, 2017.
[32] Sarah Doherty Granoff, Conversations on the Spectrum, Octopi With Hats, Browser, Summer 2017.
[33] Sarah Doherty Granoff, interview by author, New York, November 13, 2022.
[34] Sheena M. Miller, “The Potential of Serious Games as Mental Health Treatment,” Portland State University, Paper 148 (2015).
[35] Theresa M. Fleming et al., “Serious Games and Gamification for Mental Health: Current Status and Promising Directions,” Frontiers in Psychiatry 7, Article 215 (January 10, 2017): 1–7.
[36] Paul Ruffino, “Seeking Deep Relations in a Precarious Industry: Addressing Mental Health through Independent Videogame Development,” Television & New Media (2021): 1–16.
[37] L. M. Reynolds, P. Hodge, and A. Simpson, “Serious games for mental health,” Journal of psychiatric and mental health nursing24 (2017): 183–184.
[38] Andrew Robinson and Jeffrey Cruz, “Symmetra: A Better World,” Blizzard Entertainment, March 13, 2016.
[39] Allegra Frank, “Overwatch fan theory about Symmetra finally confirmed by Blizzard,” Polygon, March 9, 2017, https://www.polygon.com/2017/3/9/14873308/overwatch-symmetra-autistic.
[40] Joshi Zhang (@ZhangJoshi), “Symmetra’s voice lines … (Thread),” Twitter, September 30, 2022, https://twitter.com/ZhangJoshi/status/1575933451353526272.
[41] Sarah Doherty Granoff, interview by author, New York, November 13, 2022.
[42] Sarah Doherty Granoff, “The Essay: On Control’s Life-Changing Jesse Faden, An Autistic Person Akin To Our Newest Writer,” The New York Videogame Critics Circle, July 20, 2022, https://nygamecritics.com/2022/07/20/the-essay-on-controls-life-changing-jesse-faden-an-autistic-person-akin-to-our-newest-writer/.
[43] Sarah Doherty Granoff, interview by author, New York, November 13, 2022.
[44] Tim Rattray, “Recommending a Game-of-sorts to Ease Quarantine Loneliness,” Medium, May 2, 2020, https://medium.com/@timrattray/recommending-a-game-of-sorts-to-ease-quarantine-loneliness-6f3a3b0827e8.
[45] Dia Lacina, “What Hellblade: Senua’s Sacrifice gets wrong about mental illness,” Polygon, September 15, 2017, https://www.polygon.com/2017/9/15/16316014/hellblade-senuas-sacrifice-mental-illness.
[46] Katie Salen and Eric Zimmerman, Rules of Play: Game Design Fundamentals (Cambridge, Mass.: The MIT Press, 2004), 93–99.
[47] Katie Salen and Eric Zimmerman, Rules of Play: Game Design Fundamentals (Cambridge, Mass.: The MIT Press, 2004), 93–99.
[48] Mark Brown, interview by author, New York, November 25, 2022.
