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How Video Games Can Improve Dialogue on Mental Illness

While there are strong arguments for the games' unique potential as vehicles for a deep, experiential understanding, it is our experience that these kinds of mental health games tend to polarize.
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Co-authored by Doris C. Rusch, Ph.D., assistant professor for game design, and Anuradha Rana, MFA, MA, instructor in digital cinema at DePaul University.

The darkness is closing in around you. You know what to do to make it stop, to keep the rising anxiety at bay -- you perform the ritual that has become so familiar, it's almost a part of you. A ritual that is both cure and curse. Curse, because it keeps you stuck in a labyrinth without exit. You don't want to be stuck anymore, compelled to go through the same motions over and over again. But the alternative is unthinkable, scary. Still, doing nothing will keep you trapped in this cycle forever. You could try to break out. What if you faced and endured the fear? You stop, wait. Darkness engulfs you. It sounds like an army of tentacle monsters is getting ready to have you for dinner. But it's just an illusion. The danger feels real, but it isn't. If you don't give in to the urge of performing the ritual, a way out becomes possible -- a light appears somewhere in the darkness. It points towards an exit. You approach it. You leave.

You just beat "Through Darkness," a video game about obsessive-compulsive disorder. More importantly, you just experienced the struggle associated with resisting an overwhelming urge. The game can only be won by not giving in to that urge (just like OCD cannot be overcome by continued obsessive, compulsive behavior). "Through Darkness" is one of four short games that we -- a team of students at DePaul University in Chicago and Doris C. Rusch as game design faculty, producer and designer -- made as part of the interactive documentary, For the Records. The other games deal with an eating disorder, bipolar disorder and attention deficit disorder. For the Records is intended to make the lived experience of mental health issues tangible to a broad audience in order to increase understanding and alleviate isolation and stigma.

While there are strong arguments for the games' unique potential as vehicles for a deep, experiential understanding, it is our experience that these kinds of mental health games tend to polarize. As seen with Rusch's previous games, "Elude" (a game about depression) and "Akrasia" (a game about substance abuse), the discourse around what games are supposed to be and what they are allowed to model is complex and filled with strong opinions.

How games can improve a dialogue on mental health?

Many social problems surrounding mental health issues are founded in insufficient understanding of the fullness of experience (not merely the cognitive understanding of symptoms or physio-psychological mechanisms). Lack of such an experiential understanding contributes to stigma and often burdens relationships between people with mental health issues and those without. For friends, family and providers of people struggling with mental illness, this can complicate the difficulties of constructively dealing with aspects of the disorders, leading to feelings of helplessness, frustration and anger, and fueling the experience of stigmatization, isolation and disconnectedness by persons with mental illness.

Games are excellent tools to enable embodied, first-hand experiences, as renowned educational game researcher James Paul Gee states in his book What Video Games Can Teach Us About Learning and Literacy. No other medium allows you to truly experience life from somebody else's perspective, to take on new identities and explore what the world feels like, walking in someone else's shoes. That is because game rules create realities. By submitting herself to the rules of the game, making choices and having to deal with the consequences of these choices, the player gains first-hand, lived, embodied experience of the world that the game models, and her role within it. This is fundamentally different from experiences other media provide, which only allow you to witness someone else's choices and consequences. While we might feel empathy for someone struggling with depression in a movie, we may remain oblivious to the forces that bind the protagonist to the bed. We see the symptoms, but not the sources.

Games are different in that regard. Instead of describing: "X just didn't have the energy to get up," games can take the ability of movement away from the player. You might want to get out of bed, but you just can't. Willpower has nothing to do with it, which is an important realization particularly for friends and relatives of persons who are depressed.

Why mental health games irritate and what we can do about it.

As powerful as they can be, games like these also have a tendency to irritate. They provoke, disturb and trouble players for various reasons. One is that they rub against the expectations we have of games as a medium dedicated to our entertainment and instant gratification. Games ought to be fun, right? Don't we play them to escape our meager, little lives, our human limitations? Don't we embrace athletic, resourceful Lara Croft precisely because she makes us feel hardcore and powerful? Why would anyone want to play a game that puts you in the position of someone with a debilitating mental illness?

It's this expectation (that games are supposed to facilitate power fantasies) that keeps the medium from growing up, from expanding its emotional range, and from taking its place amongst other works of art that tackle the whole bandwidth of the human condition. The only counterargument to "But mental health games aren't fun!" is don't play them. AAA mainstream games won't go away because of them. The existence of Ulysses did not prevent the writing of 50 Shades of Grey, either. No reason to hate.

But games about the experience of mental illness can irritate for other, more complicated reasons -- their rules model "what it feels like." They embrace the subjectivity of someone's lived experience and might thus portray this experience as more desperate or hopeless as the friends, relatives or therapists want to believe. Of course, it's not an objective fact that meeting friends is impossible during depression. Believing that there are effective strategies to catapult oneself out of a depressive phase and overcome feelings of hopelessness is an important part of recovery.

It's equally important, however, to accept that it might not feel that way to those who are depressed. No one says it should stop with this acceptance, but it would be helpful if any kind of dialogue about mental illness, let alone therapeutic process, began with as much of a shared understanding of the experience as possible. There's value in acknowledging these inner truths, as desperate as they may seem, rather than denying them. We can go from there together, as collaborators on the road to recovery, rather than perpetuators of patient/provider misunderstandings and power imbalances.

Another source of doubt about these types of video games is the question about the games' "correctness" and the adequacy of their modeled experiences. How do we know that what they make us feel is an accurate representation of what, for example, obsessive compulsive disorder, eating disorder or bipolar disorder feel like? Both are valid concerns. As we see it, the gameplay experience is always a collaborative effort between designer and player. Without the willingness to take the game seriously (any game, for that matter), its potential emotional impact will be diminished.

Also, as with any medium, the factors that enable personal resonance are complex and are located on the side of the medium just as much as on the side of the recipient. The game might "hit the spot" for one player but not for another -- or it may resonate today but not tomorrow. There's no guarantee that whatever experience is inscribed within the rules and mechanics of the game and its audio-visual design, is retrieved by the player.

Embracing subjectivity of embodied experience
Although there will always be deviations and different interpretations, the range of experiences afforded by a game is not random. Why should we be less inclined to live with a certain ambiguity in games when we expect it as a mark of high quality in other media?

As for the "correctness" of the inner truths mental health games model (regardless of what players experience when they are playing them): Obviously, there are always abstractions. To claim that one could model the whole complexity of living with a mental illness would be an irresponsible overstatement.

One can only focus on salient aspects of it. Are these salient aspects true "across the board"? Probably not. While there are common denominators, the misdiagnoses of mental health issues point towards the diversity of their subjective instantiations. Everyone's depression, OCD, bipolar disorder, eating disorder -- you name it -- has a different flavor. Does that mean any attempt at understanding and modeling other people's experiences is doomed to fail?

Not at all.

Two things were important to us when we designed the games for For the Records: one, including people with lived experience in the design process. All games in For the Records have been produced either with people in leading roles who have lived experience of the mental health disorders portrayed in the game, or in close collaboration with them. For the latter, there was a constant dialogue and exchange between us -- as designers and subject matter experts. Feedback to play tests was the main guideline for design iterations. Doing their experiences justice seemed like the best way to ensure the games' integrity and phenomenological accuracies.

The second important thing to promote understanding and ease players' concerns about the authenticity of the modeled experience is to be transparent about this subjective design approach: to communicate clearly that each game is only one voice from a polyphone choir that is more or less dedicated to the same song.

Without the individual voices, the choir would not exist. It's worth listening, and it's worth leveraging the unique experiential potentials of video games to make these voices heard.