7

PORTRAYING MENTAL ILLNESS THROUGH INTERACTIVITY

[Content warning: this chapter includes mentions of self-harm and suicide.]

VIDEO GAMES INCLUDE A WIDE ARRAY OF MENTAL illness portrayals, a fact that stands in contrast with the dearth of depictions of physical disabilities. About 24 percent of video games include characters with mental illnesses.¹ I brushed up against this point in the previous chapter in which I make the case for how depicting disability in video games ultimately challenges the interactive and ability-focused nature of games. Mental illness does not seem to require the same interactive consideration, and it appears to be a go-to character trait to motivate drama. Look no further than many military-themed games, and you will find several characters with post-traumatic stress disorder (PTSD). The protagonist of Spec Ops: The Line (Yager Development, 2012), for example, suffers from dramatic hallucinations and emotional trauma from his military service. On the other end of the spectrum, the indie game scene is full of games with twee characters with mental illnesses. It seems that an efficient way to imbue a low-budget game with gravitas is to write characters with depression and anxiety. Horror games are also rife with mental illness portrayals, though they are played as fear-inducing tropes. With the variety of games featuring mental illness as either a theme or a character trait, there are relatively few that engage with mental illness in ways that capitalize on the strengths of the medium.

Telling a story about mental illness is not the same as depicting mental illness through gaming: the former is a narrative machine, and the latter is an ability machine. What I dissect here is the ability-side of portrayal, namely that of interactivity. In her model of how to categorize mental illness depictions in gaming, Kelli Dunlap makes the point that video games can offer portrayals not only through “characters, settings, and stories but also through a game’s mechanics.”² Similar to the previous chapter, the discussion to follow targets any depiction of mental illness that is specific to the medium of video games. And, also like the previous chapter, I ignore narrative portrayals: just because a game says a character has depression does not mean that the game “plays” as if the character has depression. Case in point, readers will undoubtedly think of any number of games that portray mental illness, and they will wonder why I did not include their favorite examples as case studies in this chapter.

Many games approach mental illness as a narrative theme but do not engage in interactive depictions. Two popular examples are Celeste and Depression Quest. Celeste’s protagonist Madeline experiences anxiety, and the game’s dialogue makes that clear at several points in the story. The game’s villain is, in fact, Madeline’s anxiety personified as a purple doppelgänger, and the story concludes with Madeline making peace and even fully loving that part of her identity. However, despite the heavy use of anxiety as a character trait and a theme that drives that game’s mechanics—climbing the game’s titular mountain quickly becomes a metaphor for Madeline’s overcoming of her own personal challenges—the game does not portray anxiety in any game-focused or interactive way. There are two small moments where players help Madeline calm her anxiety through a breathing exercise, and while those moments fit this chapter’s interactive focus, they are too fleeting to be case studies. Similarly, Depression Quest puts players in the headspace of a person living with depression. The game uses a visual novel format—descriptions followed by text choices—that attempts to use interactivity to portray depression: some choices are crossed out, implying that depression is limiting thought processes necessary to make those choices. But those eliminated choices were never choices and thus are simply extensions of the game’s text descriptions. While both Celeste and Depression Quest are fantastic games that deftly explore their respective themes, they do not offer enough in terms of interactivity or other game-centric portrayals to justify their inclusion in this chapter.

With so many games featuring mental illness, I am less interested in reporting a systematic review of mental health portrayals. Instead, my goal is to consider the possibilities: What are some of the techniques unique to video games? Which design decisions convey what it is like to experience mental health challenges? How do these techniques succeed, and which ones fail? There are certainly many dozens of games that use interactive mechanics or approaches unique to video games to depict mental illness. I chose the games featured here because they are a good launching point for a broader conversation about what it means to portray mental illness in interactive media. Before starting that conversation, I provide some context for the relationship between media and portrayals of mental illness.

Mental Illness, Media, and Video Games

If someone were to ask me to summarize how mass media represents mental illness, my response would be “not well.” And I don’t believe my answer would surprise anyone. Horror movies, news reports, tabloid celebrity meltdowns, television dramas, and even children’s cartoons share culture’s predominant paranoia (metaphor intended) about people with psychosocial disabilities. The research on these depictions is well-established. Otto Wahl has documented media portrayals of mental illness for several decades, and time and again the results are disappointing: mental illness is often an object of ridicule in entertainment media, and characters with mental illnesses tend to be written as outcasts or social evils.³ For instance, one study of prime-time television found that mentally ill characters were nearly ten times more violent than other characters.⁴ Put simply, stigmatizing depictions are normal or even expected in entertainment media. News media characterize mental illness as something to be feared and a danger to the delicate fabric of society. And hopeful news stories about mental illness, such as about new medical or therapeutic interventions or about recovery, are practically nonexistent.⁵

The situation is not better in video games. Unlike TV, news, or films, research on video game portrayals of mental illness is minimal at best.⁶ What research exists reports findings that are comparable to other media. A study of the best-selling games from 2011 to 2013 found that 69 percent of mentally ill characters were violent and fit the homicidal maniac trope found in other media.⁷ The remaining 31 percent of characters with mental illnesses all demonstrated socially negative or stereotypical behaviors. More targeted case studies support these findings. An analysis of Batman: Arkham Asylum (Rocksteady Studios, 2009) found the mentally ill character representations to be stereotypical and discriminatory.⁸ Many popular or even famous video game characters have mental illnesses, but their portrayals are far from nuanced, to say the least.⁹

These negative portrayals are not without consequences: they inform public opinion about mental health, and public opinion can translate into policies that unjustly affect people with psychosocial disabilities.¹⁰ Not only are media portrayals of mental illness robustly negative—in both news and entertainment—such depictions result in reduced help-seeking behaviors, self-esteem, medical adherence, and general recovery.¹¹

Endlessly documenting poor portrayals are getting us nowhere at this point, and Heather Stuart argues that we should work on “the more challenging prospect of how to use media to improve the life chances and recovery possibilities for the one in four people who live with a mental disorder.”¹² Such efforts are not wasted. For example, an antistigma advocacy program in England resulted in an increase in positive news articles about mental illness.¹³ A research team examined a large group of studies on public opinion regarding mental health, and their findings are hopeful. The public has improved in its understanding of what causes mental illness and the benefits of seeking treatment.¹⁴ Some even look to video games themselves as tools to improve public attitudes about mental illness.¹⁵

Depicting Mental Illness through Interactivity

Similar to the previous chapter about depictions of disability, I intentionally focus on game-centric techniques to portray mental illness. And those techniques may include a variety of interactive systems, such as inputs, decisions, mechanics, and others. As I stated in that previous chapter, if a game’s audiovisual design relies on interaction to witness, such as through exploration or camera movements, it counts. Once again, story and characters do not bear much weight in this conversation since story is not unique to video games and interactivity. Just because a character has a mental illness, it does not mean that interactivity is involved.

Given the sheer amount of video games which include characters with mental illnesses, up to 24 percent of all games, I purposefully limit the case studies here to a few examples that explore games’ potential for depicting mental illness. These case studies stem from a research project of mine that I published in the journal Loading a few years ago.¹⁶ And while each year finds games released with mentally ill characters, the following case studies appear to cover the breadth of what interactivity can accomplish in the portrayal of psychosocial disability. As I explained in the previous chapter, some of these depictions are innovative while others reinforce harmful tropes, but all of these portrayals could only exist in the interactive medium of video games.

Edith Finch

In What Remains of Edith Finch, players explore a labyrinthian home of the large and eccentric Finch family. The game is played in the first person, controlling a young woman in her twenties as she attempts to make sense of her heritage. She is in the late stages of pregnancy, a fact that players learn by pointing the game’s camera downward to see a very pregnant belly. She wants to understand who her family was and what traditions or curses or other vestiges of the past may haunt her and her soon-to-be-born child. When players direct her to different parts of the house, the game transitions to mini-games that tell the stories of individual members of the Finch household. As examples, in one section, players experience a bath as a baby while hearing parents argue in the other room. And another part of the game finds the player as a recluse who lived in the basement for most of his life. A robust variety of mini-games and stories populate the world of Edith Finch.

While some could assume that several of the mini-games tell the stories of people with mental illnesses, only one part of the game explores themes of mental health explicitly: the story of Lewis Finch, Edith’s video game-loving brother. Upon entering Lewis’s bedroom, the player finds a letter written by Lewis’s psychiatrist. A voice-over track of the psychiatrist plays, reading the letter while the game transports the player to Lewis in a flashback. The game fades to a scene where players control Lewis in the first person as he works at a fish cannery: by moving the computer mouse or gamepad joystick from left to right, players grab fish, move them to a large slicing machine that chops off the fish heads, and then slide the fish bodies to a bin. Gradually, as part of Lewis’s daydreaming during the monotony of his job, another mini-game appears in the top left of the screen, which lets players control a top-down role-playing game with the left hand while their right hand continues to chop fish (see fig. 7.1).

The role-playing game fantasy gradually becomes a form of detachment and mental disassociation for Lewis, and the role-playing fantasy slowly grows throughout Lewis’s story until it engulfs the entire screen. It becomes a first-person role-playing game where players control Lewis’s avatar as he performs quests, marries a prince or princess, and is ultimately coronated. Throughout this entire process, players continue to chop fish, even though the fish become a part of the fantasy (see fig. 7.2). During the mini-game, the psychiatrist’s voice-over narration explains Lewis’s depression, substance abuse, and disassociation episodes. This section of the game ends with Lewis’s suicide, which is depicted as his coronation, even though the game implies that, in the real world, he places his head in the fish-chopping machine and decapitates himself.

Figure 7.1. Screenshot of gameplay from What Remains of Edith Finch. The image shows Lewis’s hand in a rubber glove, handling a chopped fish while another fish appears on the left of the screen to be chopped. In the top left corner of the screen, there is a top-down roleplaying game that represents Lewis’s daydreaming and detachment from the monotony of his job. Screenshot by author.

The game portrays Lewis’s mental illness—in the form of disassociation and detachment—through its audiovisual design and control system. First, the audiovisual design changes throughout Lewis’s story. It begins with players only seeing his hands as he methodically chops fish. The voice-over narration describes his struggle with depression and substance abuse, and gradually the top left section of the screen opens like a thought cloud in a comic book. This new section of the screen shows a simple top-down role-playing adventure game that players control with their left hands. This alternate mini-game grows in size on the screen throughout the story, eventually overtaking the visuals of the fish cannery, portraying how Lewis has nearly completely disassociated from reality. Lewis’s video game fantasy also changes in its audiovisual design. It begins with a simple 2D character in a top-down dungeon maze, and then it morphs into more and more advanced graphics and camera angles, portraying the increasing intensity of Lewis’s detachment from reality. The story ends with a first-person perspective with relatively detailed graphics and 3D environments. It is also worth noting that the fish cannery is overwhelmingly dark, bloody, and bland while the role-playing fantasy is vibrant and sunny.

Figure 7.2. Screenshot of gameplay from What Remains of Edith Finch. The image shows Lewis’s fantasy of a third-person roleplaying game that players control with the left hand. The image includes a large fish blocking a door in the roleplaying fantasy which opens when players continue to chop fish heads. Overlayed on the roleplaying game fantasy is Lewis’s hand and the fish he continues to chop. Screenshot by author.

Second, the game’s control system during this story helps distinguish the “reality” of the fish cannery and the “fantasy” of the role-playing game while all the while keeping both active in the player’s mind. One hand controls Lewis’s actions in his dissociative episode while the other hand continues to chop fish in the cannery. When played with a mouse and keyboard, the way I played the game on my computer, I would move the mouse left to grab a fish, move it right to chop its head, and then move it up to dispose of the fish. The repetitive action continues throughout most of Lewis’s story even when the role-playing video game fantasy envelops more and more of the screen. My keyboard’s W, A, S, and D keys controlled the fantasy character’s movements while my mouse-hand continued with the monotonous task of chopping fish. Put simply, one hand controls Lewis’s fantasy while the other hand controls his reality.

The primary strength of Edith Finch’s portrayal of psychosocial disability is how it compassionately empathizes with the experiences of people with mental illnesses. The game primarily portrays detachment from reality, as well as from meaningful relationships, and its control system and audiovisual design simulate that detachment: Lewis’s dissociative episode overtakes the game screen and the separated controls between the player’s hands keeps one part of the player’s attention grounded in Lewis’s “reality” while the other plays in the “fantasy.” This control system not only operates as a metaphor for Lewis’s depression and detachment, but it also invites players to engage physically in this bifurcation. Early in my academic career, I wrote about corporeal empathy, or how games invite us to feel physical experiences on behalf of video game characters.¹⁷ Edith Finch invites corporeal empathy for Lewis’s mental health struggles by physically requiring players to experience both parts of his life, including the fantasy life that gradually overtakes reality. I believe that this physical engagement makes Lewis’s story—and the stories of the many people who feel detachment, disassociation, and depression—more relatable.

This interactive portrayal of mental illness may also be supported by research on related subjects. In the game, Lewis demonstrates many symptoms of depression, such as disengaging in reality and losing interest in important relationships. He uses video games as a form of escapism: from reality and from his most painful symptoms. A research study found that games’ virtual architecture, geography, and re-creation of locations invites escapism, a phenomenon featured in Lewis’s fantasy that gradually increases in graphical fidelity.¹⁸ One study found that escapism is a common experience found among people who engage in pathological gaming, including players with depression. And this escapism allows these players to ignore the difference between their “ideal” selves and their “actual” selves.¹⁹ Those findings coincide with another study that found that players who were motivated by escapism were also more likely to engage in pathological gaming.²⁰ Other research found that some forms of violent gameplay may make players disengage with the typical moral systems of everyday life, a finding suggesting that playing games can lead to a form of moral escapism.²¹ But perhaps Lewis’s use of video games to mitigate his mental illness symptoms would not be entirely harmful. Leonard Reinecke found in a series of studies that players can use games to cope with mental illnesses. Specifically, he notes in one study that people “with deficits in social support are forced to rely on other coping resources when facing work-related fatigue or daily hassles” and “computer games might serve as an alternative resource that facilitates recovery.”²² This finding maps onto Lewis’s fatigue in his monotonous job and his use of video gaming—or the fantasy of a video game—to help him get through his day. In another study, Reinecke found that playing casual video games at work can help workers recover from strain and stress.²³ In short, the interactive systems for portraying mental illness in Edith Finch relates to both video games’ potential to help, as well as hurt, when it comes to mental health.

Edith Finch’s depiction of mental illness is not without fault. The story focuses on Lewis’s ineffectual attempt at recovery, furthering the common public misconception that mental health challenges are permanent, unchangeable, and always doomed to worsen. Both the audiovisual design and the control system emphasize the worsening of Lewis’s symptoms as well as his social isolation, alone at his job and away from his family. And the fact that his story ends with a suicide, a common and even overused story beat, only continues the harmful trope that people with severe depression will always eventually end their lives. These tropes are not reflected in reality: many people with depression recover from their symptoms, and plenty of people with severe chronic depression live full and meaningful lives.

Hellblade

Hellblade: Senua’s Sacrifice is an action combat and puzzle game based on Norse and Irish history and lore. The over-the-shoulder third-person perspective showcases highly detailed 3D environments, and the graphical fidelity is comparable to a major game studio release even though Hellblade is an indie game. Players control the titular Senua, an Irish Pict warrior, as she journeys through a vision quest in hell to rescue her dead lover from Hela, Norse goddess of death. However, the game quickly blurs the lines separating Senua’s visual and aural hallucinations, symptoms of her psychosis, and the hellish monsters and dangerous geography surrounding her. Players quickly learn that her adventure in hell acts as a metaphor for the challenges Senua faces due to her mental illness, challenges such as social isolation from her tribe, the trauma stemming from the violent execution of her lover, and the general discomfort of her often-horrific hallucinations. Most of the gameplay consists of exploring a variety of areas, ranging from quiet forests to horrifying hellscapes, and solving puzzles based on Senua’s visual hallucinations. Players also fight various stock monsters that appear in key sections of the game.

Senua experiences visual and auditory hallucinations indicative of psychosis, a symptom which the American Psychological Association defines as follows: “An abnormal mental state involving significant problems with reality testing. It is characterized by serious impairments or disruptions in the most fundamental higher brain functions—perception, cognition and cognitive processing, and emotions or affect—as manifested in behavioral phenomena, such as delusions, hallucinations, and significantly disorganized speech.”²⁴

Difficulty with reality testing is a key characteristic of psychosis, referring to an individual’s ability to distinguish between fantasy and reality as well as between self and nonself. The hallucinations and delusions therefore present a challenge to a person experiencing psychosis: while any individual may experience an aural or visual hallucination, a person with psychosis may not be able to distinguish it from reality.

The symptoms of seeing and hearing hallucinations—sometimes shortened to simply “hearing” and “seeing”—both help and hurt Senua: for example, the near-constant ramblings of voices that players hear as Senua’s aural hallucinations guide her to safety as well as deride her. Her seeing reveals solutions to puzzles and advances the game’s story, but they also produce monsters and throbbing, intimidating environments.

The game’s approach to interactively depicting mental illness is relatively nuanced while maintaining the intense highs that accompany combat, puzzle solving, and action set pieces. Hellblade’s portrayal of mental disability relies on four primary themes: mental illness as a gift, mental illness as a process of overcoming challenges, mental illness as a curse, and mental illness as a scientifically grounded phenomenon represented in media through expertise. And these themes emerge through game mechanics and audiovisual design.

First, Hellblade portrays Senua’s mental illness as a gift through game mechanics. Mechanics are rules that decide what players perceive as their choices and limitations in a game, and those rules prioritize particular player behaviors. For instance, a regularly occurring puzzle in the game consists of a locked door that can only be opened by finding certain Norse runes inscribed on the door. But instead of finding a written or etched symbol, players must rely on Senua’s unique perspective as a person with psychosis. People who experience psychosis occasionally describe seeing patterns or repetitions in the world, and so it is with Senua. To find the correct runes to open a door, players must move around an area until they see shapes that form from the game’s environment. At its simplest, it requires finding lines, shapes, or shadows in the environment that match the same (see fig. 7.3). At its most complex, the player must align the character so that distant objects generate the shape of the rune. Upon witnessing the required runes, the door unlocks, and players may continue with the game. Another, somewhat similar, visual puzzle often appears in the game that consists of shattered images floating around an area. Players must align Senua and the game’s camera so that the dozens of broken images match up next to each other to form a complete image. Upon completing this puzzle, the object represented in the image becomes a reality: an image of a staircase becomes steps Senua can use to ascend to another level of the area.

Figure 7.3. Screenshot of Hellblade: Senua’s Sacrifice. The image shows a rune puzzle wherein players must move Senua and align the game’s camera so that distant objects appear to create the shapes of Norse runes. This image depicts a shadow on a cavern wall, which resembles the Norse rune Mannaz. Screenshot by author.

The game’s audiovisual design also often depicts Senua’s psychosis as a gift, primarily through vibrant colors and other visual effects. Players will sometimes see beautiful hallucinations, such as Senua walking through a field of oversaturated and otherwise vibrant colors. At other moments in the game, players witness visual effects that render images as glowing or repeating, and these effects are grounded in interactivity: the visual effects adjust as players move through an area. An in-game documentary about the making of the game, which is easily located in the game’s main title menu, describes this visual effect as similar to looking through a kaleidoscope. Additionally, the auditory hallucinations can be helpful in the form of providing tips to players, such as telling them where to go in an area or what to do to save themselves in a moment of combat. The voices Senua hears act almost like Spiderman’s spider-sense, which warms him of incoming dangers: the game treats her hearing symptoms as a superpower or gift, at least some of the time.

The game’s treatment of Senua’s psychosis as a gift is not some hidden metaphor buried in a literary analysis of the game: it is a prominent feature. The game’s puzzles, and more importantly their solutions, stem directly from Senua’s psychosis. The audiovisual design of the game depicts her hearing and seeing symptoms as occasionally beautiful as well as helpful to her quest. Put simply, it is crucial to recognize that the game portrays Senua’s symptoms as a superpower, an ability that others would not have that allows her to progress in her quest to rescue her loved one.

Second, the game also depicts mental illness as a process of overcoming challenges. The rules of the game allow players to quickly restart and retry challenges, such as combat encounters, after failing those challenges. If Senua falls to a monster, the game quickly reloads, and players may promptly begin the fight again. And the game connects this game mechanic to her struggle with her symptoms: in the game, she recognizes that she died when fighting a monster, and she sees that black scarring on her arm—a visual indicator of the number of times she has died and returned to fight—grow further up her body. Her failures upon facing challenges from her psychosis exacerbate her symptoms, at least in the token form of the scarring on her arm. Her mental illness, therefore, is not a static gift or an insurmountable curse. It is a continual fight, a repeating challenge that she may sometimes successfully overcome and sometimes fail. It is a process, not just a diagnosis or a trait. The game’s mechanics make Senua a hero capable of overcoming the challenges her mental illness presents. It emphasizes that she is an emotionally resilient, physically strong, and intellectually gifted person who works toward managing her mental illness symptoms.

Third, Hellblade portrays mental illness as a curse, a metaphorical hell she must traverse, and it primarily relies on game-centric audiovisual design to do so. Senua’s descent into Helheim, a hell from Norse lore, is sculpted by her symptoms of hearing and seeing. The monsters and the often-creepy areas all appear as hallucinations. If it was not perfectly clear to players that her entire journey through hell stems from her psychosis, the game ends by distinguishing between Senua’s hallucinated adventure and reality. She appears in the real world having let go of her perceived need to resurrect her lover, bookending the game by clearly delineating her previous adventures as a series of hallucinations. Also, during her time in Helheim, players see a black scar that grows on her right arm that she explicitly describes as a physical manifestation of her mental illness, what she and her tribe call her “darkness” or “curse.” But upon completing her quest and recognizing that she is in the real world and not in Helheim, the scar is nowhere to be found on her arm. Regarding her aural hallucinations, the voices Senua hears, when not helping her, often taunt, torment, or trick her. The voices were recorded using 3D binaural technology, and if players wear headphones the voices appear to surround players’ heads. If the reader has not experienced a binaural audio recording, look one up online and be sure to wear headphones. The experience is uncanny. The effect tricks your brain into thinking the sounds you are hearing are coming in the spaces around you, both near and far. In Hellblade, the result is a near-constant barrage of voices throughout the game that feel like they are whispering next to the player’s ears. It is an uncomfortable experience.

Fourth, the game makes an explicit attempt to remind players that its depiction of mental illness, specifically psychosis, is the result of research and expertise. Immediately upon opening the game, a series of splash screens appear that inform players about the game’s background and intentions when it comes to its portrayal of psychosis:

WARNING This game contains representations of psychosis. People with experience of psychosis as well as professionals in psychiatry have assisted in these depictions. Some may find these depictions disturbing, including those who, themselves, may have had similar experiences. If you would like to find out more about psychosis and mental health difficulties visit: www.hellbladehelp.info.

The game’s end credits also include extensive lists of researchers, doctors, and other “mental health advisers” who informed the game’s approach to conveying mental illness. The game emphasizes this fact by placing an option directly in the title menu to watch a thirty-minute documentary about how the game designers researched psychosis for inclusion in the game. Much of the documentary’s runtime includes interviews with people with psychosis. Quotes from interview subjects appear as text on the screen which describe their experience with psychosis. The quotes include the following:

“Everything seems to be coming closer and bigger all the time.”

“Everything is in bits. Like a photograph that’s torn and put together again. If you move its frightening.”

“When I move quickly it’s a strain on me. Things go too quick for my mind. They get blurred . . .”

“I often see waviness and melting of the walls. It makes me feel nauseous.”

“At times there is nothing to hold onto and I go into a trance.”

“The mind goes blank and everything gets switched off.”

Each quote is accompanied by in-game footage representing how the game’s developers included these experiences in the game. As examples, for the quote that reads, “Everything seems to be coming closer and bigger all the time,” the documentary shows a moment from the game where a visual effect makes the environment pulse toward the camera and then away, repeatedly. Accompanying the quote about the photograph being torn and put back together, the documentary shows one of the shattered image puzzles that players must solve. The documentary makes an explicit effort to demonstrate how game development decisions were informed not only by researchers and doctors but also by people who experience symptoms of psychosis. As an aside, I particularly appreciated how the documentary represented people with psychosis because the video portrayed them as reasonable, well-spoken individuals, and valued participants in the game’s development.

In terms of evaluating Hellblade’s portrayal of mental illness, the game excels at inviting empathy as well as showcasing the often-contradictory nature of experiencing severe mental illness symptoms. The game invites empathy by re-creating symptoms in a virtual, interactive environment: in-game portrayals of the hearing and seeing symptoms, including both the scary and the beautiful, presents empathetic opportunities for people who experience psychosis. In other words, the game can act as a form of peer support for players who have experienced symptoms of psychosis. As previously described in the chapter on empathy games, peer support in mental health care means a system wherein people with mental illnesses may benefit from interacting with people with similar mental illnesses. Some evidence points to how peer support may help people with mental illness.²⁵ The game’s opening splash screens, end credits, and the included documentary all emphasize that Hellblade attempts to communicate the experiences of actual people with psychosis. And this rhetorical technique may act as a form of interactive peer support by providing a way of playing the experiences of other people with psychosis.

The game is also innovative in its depiction of mental illness given how it replicates its complicated and sometimes contradictory nature. As stated previously, the game approaches psychosis as both helpful and hindering, both beautiful and horrific. Hellblade admittedly depicts the sometimes-terrifying parts of visual and aural hallucinations, but it also conveys the occasional beauty of those symptoms. Not only does the game include pleasant visuals, Senua’s mental illness helps her see patterns and advance the game’s story. Put simply, representing mental disability as something positive as well as negative, and the contradictions inherent in that approach, is a step toward portraying mental illness as a regular part of human life.

To be clear, there are absolutely downsides to psychosocial disability. People with mental illness are often stigmatized by others due to their symptoms. Others may see a mental illness as a fundamental characteristic that socially devalues that person.²⁶ People who specifically experience hallucinations encounter discrimination and must deal with an unfairly negative public image of their symptoms.²⁷ However, similar to how Hellblade portrays some positive parts of psychosis, there are some less-studied, potentially positive, aspects of mental illness. For instance, there are several positive psychological traits linked to bipolar disorder, such as creativity, spirituality, and resilience.²⁸ And one study suggests that people with mental illness, particularly schizophrenia, are significantly more likely to work in creative jobs.²⁹ Like these studies, Hellblade represents mental illness as both a challenge—specifically stemming from stigmas and social isolation, since Senua’s tribe all but ostracizes her—and as having the potential for positive traits such as creativity and resilience, both characteristics Senua demonstrates throughout the game.

The game is not without weaknesses in its depiction of mental illness. It uses psychosis as a narrative device to create an adventure story, one often fraught with horror. As such, it essentializes the experience of hearing and seeing symptoms in ways more easily depicted in a video game. Psychosis is often an easy character trait to employ by media creators since its symptoms can produce thrills, such as in horror movies. Hellblade is not faultless in this regard: the continual reliance on mental illness as a horror trope is certainly overused. The question is whether the game employed those fearful elements in a tasteful way, and I invite readers to go ahead and play the game to decide for themselves. I am inclined to say that the more terrifying elements of the game are necessary, and the research behind the game’s portrayal makes those moments feel earned.

Figure 7.4. Screenshot of Doki Doki Literature Club. The image shows a typical Japanese visual novel game screen with a painterly static background and manga-style character images in the foreground, also static. A pink dialogue box in the bottom center of the screen displays the name of the speaking character. Screenshot by author.

Doki Doki Literature Club

Doki Doki Literature Club is a psychological horror game that plays as a Japanese visual novel. The visual novel is a genre of video game with mostly static, manga-inspired art that relies on dialogue boxes to convey the story and character interactions (see fig. 7.4). Most of the gameplay consists of clicking through the dialogue boxes and simply reading the story and dialogue, hence the genre label of “visual novel.” But, like other visual novels, the game presents occasional interactive choices that affect the outcomes of the story: choose option A, B, or C, and the story or dialogue may change depending on the choice. The game is bright, the tone is bubbly, and the story, at least at first glance, follows the genre expectations of a romantic dating simulation game.

Figure 7.5. Screenshot of Doki Doki Literature Club. The image shows the glitching character art and dialogue text that gradually creeps into the gameplay. The character’s eyes and mouth are blotted out with groups of black squares, and the dialogue text is similarly glitching and blotted out. Screenshot by author.

The psychological horror emerges gradually as the player learns that this is not a typical visual novel game. Characters suffer psychological breakdowns resulting in self-harm and suicide, often accompanied with similarly grisly visuals. The text glitches and changes as if it were being overwritten, faces will suddenly alter or change to terrifying expressions, and the game will sometimes make choices for the player regardless of the player’s wishes (see fig. 7.5). After one character’s death, the game restarts without her. And after other characters similarly glitch out or suffer emotional episodes, only one character remains: Monika. Upon opening the game at this point in the story, the player is only greeted by Monika, alone in an eerie room. She calls the player by whatever name the player wrote for themselves at the beginning of the game: I used my first name in the game, which meant that Monika kept referring to me by the name “Sky.” Closing the game does not change the situation, and the game only continues and concludes when players find the game folder with Monika’s “character file” and deletes her.

The interactive mechanics in Doki Doki Literature Club, or DDLC for short, rely on themes of exploitive horror and limited agency to portray mental illness, primarily through its audiovisual design, control system, and game goals. The results are not uplifting, and I include this game as a case study to showcase how interactivity does not solve fundamental problems with most media portrayals of mental illness.

First, regarding the game’s audiovisual design, I want to stress that interactivity is still at play, similar to Hellblade and Edith Finch. The game’s audiovisual design alters as players interact with, and make choices in, the game. DDLC depicts mental illness as a horror trope, juxtaposing the innocence and childishness of the young women to the surreal evils that emerge as consequences of the characters’ mental illnesses. The game’s art and music are bright, energetic, and completely expected for a high school dating sim game. However, when players reach certain choices or other moments in the game, characters’ mental illnesses begin to emerge. Those mental illness symptoms, more reminiscent of horror clichés than considerate depictions, clash against the overly optimistic aesthetic of the game’s visual novel trappings. The game uses instances of self-harm and suicide as jump scares with startling visuals. For example, players arrive at one character’s bedroom where, upon opening the door, the game blasts the screen with a grotesque image of the young woman hanging by her neck. Another jump scare takes place later in the game when a character quickly displays a kitchen knife and stabs herself to death, once again with grisly visuals and sound cues. All of these horrific moments are the consequences of the characters’ mental health challenges, such as depression—the game makes Sayori’s depression a central part of several story beats—and codependency. Simply put, DDLC reuses old horror media tropes that depict mental illness as an excuse for horror, and, by implication, portrays mental illness as a hopeless horror that can only result in death.

Second, the game’s control systems convey a sense of limited agency as a result of mental illness. The game routinely prohibits players from performing actions that they had been free to do previously. The effect, at least when I played the game, was similar to feeling gaslighted or suffering a psychotic break from reality. Therefore, the technique of slowly reducing agency to contribute to the game’s horror also exists as a means to portray mental illness. For example, several moments of the game find the player in a position to choose which young woman they want to interact with, but during later choices the game will take control of the player’s mouse cursor to make the choice for them. Similarly, after one character’s death, players are left to stare at the corpse for two in-game days, restricting all game buttons apart from the fast-forward button used to skip dialogue. As players fast-forward the game, the dead body and its gore remain in the center of the screen. And as mentioned previously, the end of the game removes all choices from the player with the game opening to a single room with a character who endlessly muses about their relationship with you. The only choice remaining at this point is to locate the game’s file directory on the player’s computer and delete that character’s file.

The game’s goals continue the theme of mental illness as limited agency. The goal of a regular visual novel dating sim is to win the love of one of the characters. DDLC uses mental illness as a way of keeping players from attaining that goal. Sayori is the player-character’s neighbor and one of the romantic interests in the game. DDLC gradually reveals that she has chronic depression with a variety of symptoms typical of that mental illness: difficulty getting out of bed, oversleeping, poor memory, overcompensating with positivity, overeating, and eventually suicide. Her symptoms worsen as the player’s character becomes more romantically attached to her, and her death ends any possibility of attaining the game goal of winning her over. Yuri is another romantic interest in DDLC, but her mental illness—appearing to be social anxiety disorder due to her worrying, self-doubt, and self-harm cutting behaviors—leads her to obsessing over the player’s character and ultimately dying by suicide. Monika is not one of the game’s romantic options, but she exhibits behaviors found in some people with codependency and borderline personality disorder. The game portrays her psychological instability as the reason the player cannot complete any of the games pseudo-intended interactive goals given that she is the one who purposefully exacerbates other character’s symptoms: she is aware that she is in a game and supposedly corrupts the code of the other characters to sabotage the player-character’s relationships with them. Ultimately, the game uses mental illness as an excuse for eliminating the agency that one would expect in a visual novel.

The interactive or gameplay-focused depictions of mental illness in this game are abysmal. DDLC does not offer any innovative or novel approaches to depicting mental illness in terms of its game mechanics or interactive audiovisual design. Instead, the opposite is true: the game reuses old tropes of mental illness as a justification for the game’s horror. The game relies on mental illness to create jump scares, limit players’ control of the game as a form of psychological horror, and prohibit players from completing expected game goals. The game depicts mental illness as a horror-filled experience that inevitably leads to death with three of the four characters ending their lives. DDLC’s approach to portraying mental illness is as old as entertainment media itself, and it offers no new game-centric method of conceiving of mental illness.

Future Directions and Innovations

The story of how games depict mental illness, specifically through game mechanics or other medium-specific strategies, is a cautionary tale. For every innovation, as found in Edith Finch or Hellblade, there is a setback: using mental illness as a horror trope or a clichéd story beat. Whenever a game journalist or influencer celebrates how a game approaches mental illness, I immediately feel wary if only because it is actually quite easy to include mental illness in games without doing any of the heavy lifting of incorporating interactivity into the equation.

Interactive systems in video games generate tremendous meaning apart from story elements. Ian Bogost has written at length about this phenomenon he calls “procedural rhetoric,” arguing that the processes or rules in games may communicate ideas, values, metaphors, and so on.³⁰ And such is true in the games discussed here: the interactive systems of these games communicate values regarding mental health, illness, treatment, stigma, and tropes. It is surprising how often games unintentionally communicate harmful ideas through their interactivity, such as the stigmatizing tropes as seen in this analysis.

It is also surprising how often games do not take advantage of the medium’s unique strengths by using interactive systems more intentionally to communicate. For instance, while there are abundant game characters with mental illnesses, so few of those portrayals bear any actual weight on how the game plays. And while games such as Edith Finch and Hellblade found a welcome balance in their depictions that capitalize on gaming as a medium, it is still easy to slip into exploitation in cases such as Doki Doki Literature Club. In other words, I certainly don’t blame developers for not designing interactive portrayals of mental illness since it is easy to get it wrong. It is much safer to write it into a character without any gameplay deriving from that inclusion. There are better ways to make games—not just characters, but actual games—about mental illness. With these case studies as a foundation, I offer four aspects of gaming that could see further innovation regarding the depiction of mental health or psychosocial disability.

1.Control systems. Games can portray mental illness through control systems. Edith Finch is a good reference point because the game’s controls during Lewis’s story are central to its depiction of depression and disassociation. Game designers simply need to remember that game controls are an underused, yet valuable tool when crafting a game experience. Players have two points of entry into a game—namely their physical interactions with a controller and the audiovisual information presented to them—yet too many games avoid deviating from, or innovating on, control inputs. Controls have great mimetic potential, meaning they can imitate or recreate real-world phenomena in a stripped-down and accessible way. If rhythm games can use control systems to make players feel like musicians, and if action games can make players feel the intensity of a high-stakes swordfight, then other games certainly can approach their controls more critically and purposefully for the sake of depicting mental illness.

2.Audiovisual design. Games can create an immersive, and therefore empathetic, approach to depicting mental illness through audiovisual design. Hellblade relies heavily on responsive, even interactive, audiovisuals. The 3D binaural audio showcases voices that mimic the hearing symptoms of psychosis, and the wavy, colorful, or otherwise hallucinatory visuals do the same. The game does not make these audiovisual design decisions a static experience, and instead they move and respond to how players interact with the game’s world. It is often too easy to simply say “this character has a mental illness” without considering how the game may, even at the metaphorical level, depict that experience through interactive audiovisuals. As an example, if a game were to convey what depression feels like, making a game’s otherwise vibrant colors shift to more monochromatic hues would certainly aid in that endeavor. Such a design decision would be relatively simple to implement while directing players’ emotional focus toward the theme.

3.Game goals. Games can use goals to motivate an interactive experience about mental health. Games are often about choices, and they provide several goals to players in order to motivate interaction with those choices. Instead of relying on horror tropes or overly sentimental, woe-is-me depictions of mental illness that further ostracize the actual people in our lives with mental health challenges, games could include goals that focus attention on healthy management strategies. A game could portray a character with PTSD, and when a traumatic episode is triggered, players could choose from several management strategies—informed by research and professional therapists—to work toward the goal of improving the life of that character. A game about depression could use quests which guide players toward help-seeking behaviors. Or a game could include a medication routine wherein the goal would be adhering to a schedule, rewarding consistency with improved symptoms. Games should certainly avoid communicating that all mental illnesses are easily cured. But game goals are one potential avenue to portray mental illness more empathetically by giving players goals which motivate nuanced interactions with the subject matter.

4.Game mechanics. Games can use their greatest strength as a medium, the very mechanics that oversee the gameplay experience, to portray mental health. Mechanics are rules for what actions players may perform in a game. They are the most fundamental part of games. The job of a game designer is to craft mechanics, and these mechanics can communicate emotion, information, and narrative themes. The game mechanics of chess convey a royal battle. The mechanics of a first-person shooter creates fast-paced action and high stakes. Game mechanics should be the first place designers go when crafting an experience for players. Yet games too often avoid using mechanics to portray difficult subject matter, including mental illness. Perhaps this is the case because it makes the experience so visceral to players that it forces players to directly confront the subject matter, interact with it, influence it, and experience the consequences of their actions. Games which bravely invoke mechanics that support a theme, such as mental illness in Edith Finch or Hellblade, should be applauded. There is no shortcut around this fact: if designers want to convey mental illness, they should create game mechanics that do so. Each game will take a different approach, and some may fail at achieving their goal. But that is true of all subject matter in games.

My game D.Personal relies on game mechanics, audiovisual design, and game goals to convey my history of episodes of depersonalization. I have already written about that process at length in a previous chapter, but it is worth mentioning that the game would not be a game about depersonalization if it did not include game mechanics, audiovisual design, and game goals that all reinforced the experience. It would not otherwise be a game about mental health. I could always write a blog post or compose a song or paint a picture about depersonalization, but if I wanted to communicate my ideas through a game, I should do so through gameplay. While plenty of games may include written descriptions of mental illness, or tell a story about mental illness, or include a character with a mental illness, their gameplay may not be about mental illness. Portraying mental illness through gameplay requires interactivity, and interactivity changes the experience: it isn’t a narrative machine, it is an ability machine.

Notes

1. Shapiro and Rotter, “Graphic Depictions.”

2. Dunlap and Kowert, “Mental Health in 3D,” 123.

3. Wahl, “Depictions of Mental Illness in Children’s Media.”

4. Diefenbach, “The Portrayal of Mental Illness on Prime-Time Television.”

5. Wahl, “News Media Portrayal of Mental Illness.”

6. Ma, “How the Media Covers Mental Illness.”

7. Shapiro and Rotter, “Graphic Depictions.”

8. Morris and Forrest, “Wham, Sock, Kapow!”

9. Banks, Mejia, and Adams, 100 Greatest Video Game Characters.

10. Wahl, Media Madness.

11. Stuart, “Media Portrayal of Mental Illness and Its Treatments.”

12. Stuart, “Media Portrayal of Mental Illness and Its Treatments,” 105.

13. Thornicroft et al., “Newspaper Coverage of Mental Illness in England 2008–211.”

14. Schomerus et al., “Evolution of Public Attitudes about Mental Illness.”

15. Hoffman, “Social and Cognitive Affordances of Two Depression-Themed Games.”

16. Anderson, “Portraying Mental Illness in Video Games.”

17. Anderson, “Turning Pixels into People.”

18. Schwartz, “Fantasy, Realism, and the Other in Recent Video Games.”

19. Li, Liau, and Khoo, “Examining the Influence of Actual-Ideal Self-Discrepancies.”

20. Yee, “Motivations for Play in Online Games.”

21. Hartmann and Vorderer, “It’s Okay to Shoot a Character.”

22. Reinecke, “Games and Recovery,” 131.

23. Reinecke, “Games at Work.”

24. APA Dictionary of Psychology, “Psychosis.”

25. Lloyd-Evans et al., “A Systematic Review and Meta-Analysis.”

26. Dinos et al., “Stigma.”

27. Schulze and Angermeyer, “Subjective Experiences of Stigma.”

28. Galvez, Thommi, and Ghaemi, “Positive Aspects of Mental Illness.”

29. Kyaga et al., “Mental Illness, Suicide and Creativity.”

30. Bogost, Persuasive Games.