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Are we portraying mental illness in games, or are we trying to treat it with games?

A topic by Aleks Samoylov created May 06, 2022 Views: 341 Replies: 6
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I'm a touch confused by the wording here and would love some clarification. Are games submitted for this jam expected to address mental health and mental illness as a topic, with the aim of destigmatizing the illnesses themselves and creating some level of representation and awareness for sufferers (something like The Cat Lady, or Senua's Sacrifice - I think the former was more successful than the latter, but that's beside the point) ... or are they expected to function as effective therapeutic tools in their own right?

If the latter, are these intended to have real clinical applications with real medical benefits for sufferers beyond a few minutes or hours of distraction? Let's say I have severe depression, PTSD, OCD, and anxiety (I do, in fact) ... are these games expected to provide an experience that, were I to play them, would induce me to feel tangibly better in the long term, such that the game could at the very least become an ongoing additional treatment option alongside my therapy, medication, support groups, etc.? 

If so, could you provide examples of games that have been successfully used in this manner thus far, and I mean clinically and with clear, proven results, so we could have some notion of what to aspire to ... and so I could add those games to my own treatment plan, because honestly that would be amazing. Off the top of my head, the only thing I can think of is something like Superbetter, which I have tried, and which proved to be more of an overcomplicated, glorified to-do list with gamified components which ultimately did very little that a regular paper to-do list couldn't do. 

While executive dysfunction is something many of us mentally ill folks suffer from, and while it is the low hanging fruit, so to speak, when it comes to seemingly addressable issues, it ultimately results in the creation of mere productivity software and doesn't address the core issue, since the mere act of using the software / playing the game (no matter how fun it is to a healthy mind) becomes "just another thing I am supposed to do" to someone with severe illness related fatigue, motivation issues, anhedonia, and executive dysfunction, which are pretty common symptoms for a lot of mental illnesses.

It's a bit like telling a depressed person to "just exercise' or "try yoga" - those things may certainly have long term benefits when practiced with consistency and rigor, but if you're already going through clinical depression, you may have a hard time simply getting out of bed, getting dressed, or showering. Jogging or yoga are usually out of the question. When it comes to games, I can get so depressed that my favorite games of all time seem like an utter chore. I was so depressed last month, and so deep in dissociation from the PTSD, that I was utterly uninterested in anything, including playing Elden Ring. I have been letting Elden Ring (Elden Ring!) just sit there, gathering dust, for weeks! Instead I basically just stared at the wall for hours, more or less. The very thought of doing something, ANYTHING that I absolutely didn't have to do in order to simply stay alive, was impossible. 

So ultimately, any game that would successfully achieve clinical results, or even provide temporary relief during an actual symptoms heavy period (anyone can play games, or do some form of yoga, when they're feeling at least sort of okay), has to act on one's psyche so quickly, reliably, and effortlessly that it will easily and consistently be able to overcome that initial motivation barrier. It would have to be accessible in ways I can't even imagine.  It's have to be something that I could pick up and feel better within a few minutes, and that sense of improved wellness would need to last long after I stopped playing. As of right now, there aren't even any medications that can do that (safely and without severe damage and risk of addiction). Antidepressants, which are comparatively safe and have a low side effect profile, take a month on average to actually start kicking in. Anything that provides relief faster usually has all kinds of risks, dangers, and caveats. Therapy with trained professionals can take many, many years before any long term results are seen, and those results generally come in the form of improved and refined coping mechanisms at best. Most of these illnesses don't have cures, only treatments and management options. 

As you can see, I am quite interested in participating in this jam, as the topic is near and dear to my heart, but I am currently a bit skeptical if we're expected to attempt the second goal. A game ABOUT depression or PTSD is something I can make from the heart. If I were able to make a game that successfully TREATS depression or PTSD ... well, I'd have done that by now. Or if I am not fit for the task, I would have thought someone would have done that by now, and likely become fabulously wealthy as a result. I suppose I am open to trying to make "therapeutic" games if the inherent limitations of the exercise are acknowledged and addressed, and if the whole thing was treated, and judged, based on the aspirational study in hope and creativity. That would, after all, be an attempt to create a product that could literally change the world by simply existing. 

On a somewhat related note, is this a video-game only jam, or are analogue games, such as tabletop rpgs and larps, acceptable for submission? When it comes to those media, I have seen some clinical application, or at least treatment adjacent applications, since larps especially are essentially designed to create catharsis and have a strong connection to the practices of psychodrama and certain forms of therapy. Even so, these have been limited in scope so far. Obviously, anything that could ellicit "trauma reduction" levels of catharsis also has the potential to simply intensify or trigger trauma, and the legal liability issues were such games undertaken as explicit treatment, would be potentially ruinous.

Submitted

Not sure if this will help entirely, but if you haven't read through this page, it may answer many of your questions:

https://www.deepwelldtx.com/post/discover-game-jam-mechanisms-examples

Thanks. That does help somewhat, but does still leave me with some questions. 

Based on the "Move, Breathe, Feel, and Think" paradigm, I am assuming analog games, especially in the LARP format, are encouraged? While most of the examples for the Move component feature video games that use motion controls of some kind, I don't think most people participating in itch jams have access to APIs or developer kits to actually be able to make full motion control experiences, let alone test them properly, in the short time span of a jam. There is probably some open source webcam based stuff that exists out there, but I doubt such a thing would be especially newcomer friendly. 

The same goes for breathing. I am sure there are ways that I, as an indie developer, could figure out ways to incorporate breathing into the gameplay, but it would likely take me the better part of a month just to come to grips with the basic input / output implementation, let alone figure out how to work it into a design comprehensive enough to put forth as a competitive jam submission. I can think of a few basic implementations that use standard I/O (keyboard, mouse, controller) off the top of my head, but those cannot be truly interactive - the game cannot provide adequate feedback to the player without actually measuring their breathing, so it would have to rely on essentially telling them how to breathe and hoping they follow directions, or else ask them to breathe in time with their button presses, which might work with a lot of testing, but again relies on the player's ability and desire to follow directions with no way for the game to actually measure whether they are doing it "correctly" and providing them with rewards and encouragement. 

Which leads me to the next question, which would be an issue that applies to both analog and digital games. We're game designers, and are hardly experts on exercise regimens, breathing rhythms, and their effects on the body and mind. Therapists generally have to go to training and seminars for that sort of thing, and when it comes to other "interactive" therapy regimens with biofeedback components, such as EMDR (Eye Movement Desensitization Reprocessing) there is a risk of actually doing more harm than good with the wrong application of a technique.  Some of this can, of course, be remedied through research, but we hardly have the resources to do this properly within a jam context. 

A corporation would hire an expert consultant on such things, and we obviously can't do that, which means we have to spend time we could be coding or making art poring through youtube videos on yoga, medical journals, wikipedia articles, and we probably could do this for hours every day and still not scratch the surface of understanding it after a full month. I doubt it's a huge issue with the breath component (though even then, I'd be worried about users with irregular breathing patterns or conditions such as asthma, and am personally not super comfortable with my ability to tell other people how to do something as crucial as breathing), but the movement component could be potentially fraught - even light aerobic exercise has procedures and orders of operation for safety and the like. When we're talking about recreational products, like Wii sports and Just Dance, it's probably not a huge issue, since players come with no expectations and the premise is simple and scalable to individual preferences - nobody goes into one of those games expecting anything beyond a bit of waggling about. As soon as we start specifically designing games for what is essentially a very specific medical purpose, we become subject to medical levels of liability, at least in the abstract. Sure, major issues or harm are unlikely, but if the game promises that it will make you feel better, in a clinical sense and with the intent of addressing specific clinical issues, and it not only fails to deliver but makes someone sick or injured (hopefully nothing more than a sprained muscle, but still) due to improper exercise instructions given by a keyboard jockey like me who, let's face it, knows diddly squat about proper exercise, then it's no longer just a "bad game" or even a "failed game," it's now "bad therapy" or potentially even a form of "quackery."

And that ultimately brings me to the original question. If the goal is simply to make games first and foremost, and make sure those games, in some abstract way, happen to encourage players to do a bit of light movement and very, very basic breathing exercises, without explicitly promising therapeutic benefits, then that's one thing. If we are supposed to be making therapeutic tools / "treatments" first and foremost, then we're in a whole different ballgame. And I am still not sure which one of the two modalities this jam is oriented towards. I am assuming and hoping it's the former, but the wording is more than a bit unclear on that front, both on the itch page and the deepwell website, which contains a LOT of additional information that I really wish was included on the jam page, as it seems rather important. Now, obviously the video indicates that we don't have to do all of the above, or even more than one, but I kind of feel like this is another one of those tidbits that could have been placed much more front-and-center, and also doesn't really solve the underlying conundrum I am experiencing here. 

I could, for example, try to make a narrative game that incorporates CBT or DBT techniques for the "think" component, but those are modalities that cannot easily be generalized and really work best when applied to individuals and their specific situations over an extended period of time. They are also extremely deep rabbit holes and generally require training for professional therapists to be able to apply well. Just as with physical issues, and perhaps even more so, there is a danger that if someone presents these concepts as scientific fact, but does so incorrectly or incompletely, and if an impressionable player accepts them without some requisite skepticism (a younger player, for example) then it could actually cement harmful thinking patterns instead of helpful ones. 

Both DBT and CBT have their proponents and detractors, and when it comes to the latter there are some good points to consider. Without nuance and care, they can veer away from regulating negative thinking and emotions into dictating cognitive rigidity, forcing patients to minimize their traumas and immediate pain, excessive self blame ("beating yourself up") for "not doing it right," and so on, and so forth. Now, none of those things are the intent of those therapies, and while some people find the methods more or less helpful, if they are presented with nuance by a trained and competent therapist in a one to one setting most of the above pitfalls can be avoided - at worst, the patient may feel that something like CBT is simply not helping them as much as they'd like. But if you read any of the foundational texts, such as Feeling Good, on their own, and fail to parse some of the potential issues, and then start presenting half baked misreadings of CBT techniques in a generalized format, you can actually do some real damage. Since not all therapists are, sadly, created equal, I've known several people whose therapists actively made them feel worse because they themselves didn't really understand the methodologies in question. Without a lot of careful consideration, CBT can turn into "law of attraction" style  "I can think myself out of my pain, and if I can't I'm even more of a failure because it's basic science" nonsense, and DBT can turn into a complete denial of the very traumas that it's supposed to help address. And so on and so forth. In short, while talk therapy carries less stigma than medication when it comes to potential risks, the wrong cure can still be worse than the disease. At least when a patient fails to respond to specific meds, there is usually a managed procedure of stepping down and stepping up and very clear physical indicators. When you're locked into a warped process with a bad therapist, on the other hand, you may not know that there is a problem until years later.  

So I guess in the end my question is no longer whether or not we're supposed to be making games that are about illness versus games designed to address illness. It does seem clear that it's the latter. At this point I am just more concerned with the extent that these games should be labeled as "therapeutic tools" and how this can be done safely by people who, like me, have no actual expertise in something as complex and delicate as mental health.

I don't contest the assertion that games can have real mental health benefits on an individual level. But it's one thing for me to say that Dragon Age Inquisition really helped me through a rough couple of months (mostly because it happened to be new at the time and distracted me for a few hours every day - not like it taught me any actual coping skills or genuinely treated my depression), and a whole other thing for a representative of Bioware to get up on a stage and say, "here's Dragon Age Inquisition, out brand new interactive therapy for depression and PTSD."  

TLDR: I have actual OCD and autism, and once I start typing, I do not stop until every possible angle of an issue that I can possibly think of at the time has been addressed at least once, and thus there is no way for me to do an effective TLDR section without retyping everything. Sorry.

Host

Sorry for the late reply but the intent is to make games that are therapeutic tools to help people with mental health conditions with a focus on fun.

Host

We should also add that we are not looking to replace anyone’s doctor or therapist or prescribed medications. These games are considered adjunctive therapies. This link has some helpful information https://www.deepwelldtx.com/so/45O1tB_vm/c?w=wmJk7MbFm8DSR6F8EmeQ3w7iraooH7-wsja...

(+1)

Thanks for the response. I've already read through the content at that link, and while it clarifies some things, I am still finding the issue a bit tough to navigate.

I guess it boils down to the fact that, as a sufferer of several fairly severe mental illnesses and a person who plays a lot of games, I have never once, in all my years of both the playing and the suffering, come across a game that was explicitly trying to be therapeutic and actually succeeding. Any time a game has explicitly tried to do this, it felt, for lack of a better word, irritatingly preachy. Unlike a therapist, a piece of software cannot address the extremely individualized and idiosyncratic aspects of any given user's struggle, so its attempts to guide me towards feeling better usually aren't tailored to me, or even just me in that precise moment, under those precise circumstances, and thus feel like an attempt at a one-size-fits-all didactic approach. 

Now, I do play a lot of games, and I do enjoy games, clearly. And I have played many games that were able to help me kill a few dark hours here and there (only when my symptoms weren't too severe, of course, since past a certain point even something as simple as playing a game, no matter how engaging, is pretty much off the menu) but I've never played a game that genuinely alleviated any symptoms in any tangible way. I don't even feel less anxious, less depressed, or less prone to dissociation while playing, say, Myst (one of my favorite games and progenitor of one of my favorite genres) - instead, I am just an anxious, depressed, and dissociating person who happens to be playing Myst. On rare occasions, the pure escapism of a game can basically provide me a source of light distraction, and thus a bit of relief, but that's not really inherently therapeutic, is it? Maybe a coping mechanism? Maybe?

That is, unless distraction and escapism count as therapy in their own right, which I suppose I can see an argument for, though the phrasing does suggest something clinical even after the clarifications, and that trips me up a great deal. I do often appreciate that bit of distraction, despite the basically indisputable fact that as soon as it's over I am right back where I was before, no headway has been made in addressing my issues and no improvement has been made in my overall condition - I go right back to feeling just as awful as I was prior to allowing myself to get distracted, and can sometimes even feel worse if I allowed the distraction to monopolize my time because nothing else could bring any relief (essentially maladaptive self soothing). Still, "relief is relief, no matter how brief," and I understand the potential value of just killing a bit of time with something fun. However, if that's the criterion for what would be considered "therapeutic," in an adjunctive sense, of course, then don't literally ALL games, and ultimately all entertainment media, qualify as such? At least, doesn't every game serve that function for someone

So then what is disqualified? Does Tetris count because it allows many people to relax and zone out for a bit? Since I personally find Dark Souls relaxing, does Dark Souls count as a therapeutic game, despite the fact that it has apparently been known to actually heighten anxiety in others? Could I submit a dungeon crawler, a shooter, a farming sim, a point and click adventure? Does the game have to reference the fact that it's trying to be a therapeutic tool in order to qualify (thus basically ensuring its status as "educational software")? As I mentioned above, whenever a game has done this in the past, I felt patronized by it and profoundly turned off, and you've got to remember that we mentally ill folks can be a prickly and very picky bunch, and we really don't respond well to being patronized when it comes to our illness in particular. 

Now, if I am reading all the info correctly, then one can pretty much submit any kind of game so long as it centers at least one of the four tenets outlined in the article, and I suppose that's that. But it all just feels so vague and broad. For example, there are currently a bunch of games submitted to the jam that appear to be the standard bevy of cross-posted jam spam, but at the end of the day I actually can't think of a concrete reason, besides maybe the cross posting, that they shouldn't be allowed to stay up there. I mean, someone might find them to be helpful in regulating their emotions, or thoughts, or breathing. 

I don't know. At this point, it just seems like I am overthinking it (obviously am), and that this really just isn't the jam for me. And that's fine in the grand scheme of things. I just find this to be increasingly the case with mental health oriented jams in particular. I always find myself wanting to participate in one, and always realize that it's simply not suitable to my specific bundle of illnesses, which feels extra painful because you'd think these would be the jams where people like me would be able to contribute quite a bit, and would be able to feel comfortable or welcome. 

It's nobody's fault, perhaps. In this particular case, I suppose the OCD and the autism are doing the bulk of heavy lifting. Without additional clarity, I just can't conceptualize what is actually expected, and I am too afraid to attempt something that explicitly tries to help people like me in a clinical sense when I clearly can't even help myself and have simply never experienced a game of any kind or genre that I could confidently say addresses any one of my symptoms beyond simply serving as a (often maladaptive) coping mechanism. To even imagine that any work of art could serve as even adjunctive therapy feels almost trivializing to me (and I am a professional artist). These conditions are utterly devastating, and we have to live with them day in and day out. We don't get actual breaks. Even with treatment, they never completely go away, and all that regulating is often a constant drain on our energy and time that others do not have to deal with. And while I appreciate the bits of distraction and relief a game of Tetris can sometimes give us, it feels like an overwhelming, impossible, herculean task to try to plug a gaping abyss with a handful of tetraminos.

Well, either way, at this point there probably isn't enough time left for me to really submit anything anyway, but I do hope that maybe these rants can at least prove somewhat helpful to you, as feedback for future jams.  

Host

We really appreciate the thoughtful and vulnerable feedback and the whole team has been reading and digesting it on a deep level to think about how this new genre of games and venture moves forward in a mindful and intentional way with feedback like this and people like yourself in mind. I realized I didn't answer and earlier question of yours and that is that any type of game, physical, VR/AR, ARG, digital, etc is accepted for the jam. 

I suffered from deep depression and anxiety myself and can relate to that feeling of not even wanting to pick up the controller and getting no joy from games in those moments but knowing they were there when and if I needed them was always some form of comfort to me at least.

You are right therapy is a highly personal and personalized experience and it will be a major challenge for game developers to make games that can be more than just a brief distraction from the real world and offer actual therapeutic benefit in some way. I believe that game developers are some of the most creative people in the world and if given the right set of tools and knowledge from people with clinical backgrounds they can come up with ideas that will be beneficial to game players all over the world. Games have a special way of creating and building empathy and connection that most forms of non-interactive media don't have and it is why I believe it is worth trying and possible to make games and interactive experiences that can help people in need.

I am speaking for myself though and not on behalf of DeepWell but know that they have heard your feedback and appreciate it.