How are video games portraying mental health issues and what can developers do to improve that? Jem Alexander talks to and Ninja Theory to find out

Mind Games: Mental health in video games

While video games mature as a medium, so too does their ability to reflect a broader range of human issues. Mental health is a growing global concern and, as such, is something the games industry is beginning to touch on in increasingly sensitive ways. Realistic depictions of mental health issues in games can not only inform the ignorant, but also help sufferers by, for example, removing stigma. Done badly, however, this representation can do more harm than good.

“Mental disease is often pictured in a misleading way in games and other media,” says Luca Dalco, Creative Director at The Town Of Light developer “I think it is important that some games aim to be objective and try to let people become aware of this huge problem. Mental disease is, first of all,
pain and suffering.”

Because it’s an issue that affects so many people, it’s important to be accurate and realistic in the depictions of characters with mental health issues on screen. “I have studied the issue for a long time through personal research,” says Dalco. “However, first- hand experience is the key element that allows the achievement of the necessary sensitivity to face the matter properly and to understand the pain that lies behind the mental disease. There isn’t a book or a talk that can replace what you experience in your own skin, or through people who are close to you.

“Talking with mental health workers allows you to proceed with coherence, it is also a great source of inspiration and an excellent way to avoid addressing the topic in an unsuitable way that could result in being offensive, disrespectful and harmful.”

Psychological problems are very common in modern society and the best way to fight them is to talk about them

Luca Dalco,

Dominic Matthews, Product Development Ninja at Ninja Theory, agrees. The game he’s working on, Hellblade: Senua’s Sacrifice, has a protagonist who suffers from psychosis and thorough research was vital for an accurate portrayal of this in the game. “We’ve worked with people who have direct first-hand experience of psychosis, including people who experience voice-hearing, visions and unique beliefs,” Matthews says. “Through the support of Wellcome Trust, a Global Charitable Foundation that supports entertainment projects that have the potential to engage people in scientific themes, we started to work with Professor Paul Fletcher, a psychiatrist and Professor of Health Neuroscience at the University of Cambridge.

“Paul has worked closely with us, giving us amazing insight from his experience as a psychiatrist and also his work as a leading expert in neuroscience. Through Paul we’ve had the opportunity to meet with a number of different groups of people who have experience of psychosis including some people at a local recovery college in Cambridge.

“It’s good practice to research a subject area thoroughly before telling a story about it. This is especially true in the field of mental illness as it is an area fraught with stigma, misunderstanding and real human suffering. We’ve set out to depict our character’s mental health difficulties in an honest fashion based on evidence and real people. Doing so without understanding the subject first would have been a mistake. Working with leading academics and those with lived-experience has directly resulted in enriching the Hellblade experience, whether it be the style of voices, the artistic nature of the visions or the puzzles that Senua has to solve.”

Accuracy of depicted symptoms are as important as an understanding of the history of the subject. The Town Of Light is set in an asylum in the 40s, at a time when mental health was far less understood than it is now. “In the past, if you were mad you were dangerous,” says Dalco. “You were considered outrageous. Society got rid of these people and this shame through asylums, which weren’t created to heal, but to contain. Patients were not organised based on their pathology, but on their behaviour: agitated, calm, dirty, etc.

“In the 40’s a girl could have been imprisoned for their whole life in an asylum because she was considered outrageous, or because she was homosexual, or alcoholic. In the meantime, the ‘normal’ people were leading the world toward the most bloody war in the human history. We cannot and we should not forget this.”

Ninja Theory’s Matthews believes that games can be a great tool to educate players and help them empathise with sufferers of mental health disorders. “We don’t embark on this specifically to raise awareness but rather to create a compelling story and character,” he says. “However, video games do offer a unique opportunity to put players into the place of another character and allow them to see and feel the world through their eyes. By doing this Hellblade can first and foremost be a compelling piece of entertainment, but at the same time, it could go some way towards understanding a very difficult subject.

“Understanding is a route to destigmatisation. Video games can put players in the shoes of someone else to experience the world as they do. Movies can only give you a passive viewpoint, where you spectate the experiences of another. Hellblade is first and foremost a video game. A piece of entertainment that will take you on a journey. But by the end, you will have experienced a taste of what it could be like to experience psychosis in an aspirational hero. Everyone we have collaborated with, from the experts to the service users, have been very enthusiastic in their support for this very reason.”

Understanding is a route to destigmatisation

Dominic Matthews, Ninja Theory

Luca Dalco agrees: “In my opinion, games could be powerful tools to communicate with people who suffer from problems related to mental health. Psychiatry shows a growing interest in games, especially with the release of affordable VR headsets. Most of the time those who are suffering from severe mental disease tend to fully isolate themselves. Each tool that could potentially allow communicating with these people can be very helpful, but here I’m talking about specifically crafted games. As for commercial games, I think they can be a good way in helping young players to be aware of the true extent and nature of the problem, it all depends on the way games will face this controversial topic. Psychological problems are very common in modern society and the best way to fight against them is to talk about them.

“It is important to talk about mental health issues; we need to talk a lot more about them rather than ignoring them. This is the first and best thing that games can do: talk about it again and again, at least to draw the interest of young people on this topic. But we can’t only have games that deal with this topic in a serious way, and it would be unfair to demand it. Something else should be done to allow the player to understand the differences on how mental health is represented.”

Dalco makes an interesting point, here. Games are meant to be entertaining and in order to maintain that a balance must be struck. “If we are developing a game and not an interactive documentary, we can’t forget that we must entertain the player,” he says. “That balance is something subjective that depends on the story we are going to tell and the way we mean to tell it.”

With Hellblade, Matthews believes informing the player about psychosis is just a bonus on top of what they hope will be a compelling game in its own right. “We’ve never seen our role as being to inform players about psychosis, but instead create a story about a Celtic Warrior who happens to experience psychosis,” he says. “We’re not positioning the game as being about raising awareness or being educational, but we believe that by engaging players in a character, a story and a world that is different to theirs, they can not only be entertained but may also gain further understanding. By virtue of presenting psychosis in a manner grounded in reality, we’re exposing people to a fascinating subject matter that we hope offers something new.”

Developers shouldn’t shy away from tackling difficult issues. There’s a strong possibility they could, if handled properly, make the game stronger. “It would be easy to ignore complex subjects in video games out of fear of offending or controversy,” says Matthews. “But I believe that in itself is a pitfall. I believe that players want creative diversity in gaming and want games to treat difficult subjects in a mature fashion, so developers shouldn’t write off dealing with particular themes if they are passionate about them.

“We’ve also found a lot of support in the mental health community for what we are attempting to do with Hellblade, we’ve engaged a lot of people in what we’re doing, listened to them and explained what we’re doing. Many might think that this will ultimately lead to a need to compromise, but we’ve found the opposite. Our engagement has enriched our creative to make our game that much more compelling.”

Dalco’s advice for developers is along much the same lines. Take the risk, but be sensitive and research thoroughly. “A very common risk is to exploit the stigma itself as a narrative expedient to create stories that share nothing with the real mental health issues,” he says. “As an example, madness is often used to portray the worst possible murderers. This misleading way of depicting mental ill people is a possible way to stigmatise even worse.

“I’m personally convinced that in order to destroy the stigmatisation of mental diseases, the magic word is ‘empathy’. It means understanding the deep suffering that leads the lives of people who suffer from mental diseases, but it is important to understand it is not rational, but rather emotional. Games fit this need very well and I hope growing numbers of developers will use them this way.”

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