5 Golden Rules for designing ethical mental health experiences
Abstract
Mental health is one of the least understood public health concerns, despite how common mental health problems can be in the population. An estimated 10.7% of the world population suffers from some mental health disorder. The purpose of this article is to identify, define and test a set of golden rules for designing ethical mental health experiences. Firstly, we shall identify what an ethical and unethical approach might look like through a comparative analysis, from which we derive and define our golden rules and finally test them against a game (from a game critic’s perspective handled mental health ‘correctly’) using the methodology of a case study.
The stereotype of ‘crazy and violent’ creates a shroud over what is real and not by simplifying all the complexities of the various mental illnesses that have been identified today into a mere archetype to be used as a plot point encouraging false assumptions to spread. In this study on the portrayal of mental health in commercial games, from a pool of 100 reviewed games approximately 30% to 35% had characters that were portrayed as either being violent and/or as being lost, lonely, or helpless. Games need to tackle mental health in a more nuanced and compelling way to promote conversation that encourages empathy and understanding, rather than commit the centuries old crime of hubris that other forms of media have been subject to.
Comparative Analysis
I realize that mental health in video games is an extremely comprehensive topic and so I shall focus on a single level from two of my favorite games: Persona 5 (Futaba’s Pyramid) and Bioshock (Fort Frolic), each dealing with a particular character living with mental illness. One being ethical the other…not so much.
Unethical Example – Bioshock (Sander Cohen, Fort Frolic)
Let me start by saying Bioshock is a wonderful game and Sander Cohen, an intriguing character. However, looking at this from the lens of ethical mental illness representation, the game falls prey to the classic: Depicting people with an illness as inherently violent, which can then be used as a cheap motivation for villainy.
The Homicidal Maniac trope i.e. a psychopath with no particular mental illness, but rather the stereotypical violent tendencies which amount to killing people for fun or in Cohen’s case to achieve artistic fulfilment. Sander Cohen is an artist and his ‘insanity’ can be blamed partly on the use of ‘ADAM’ (an enhancement drug central to the world of Bioshock) and out of frustration for the lack of appreciation for his work. His domain, Fort Frolic, is filled with ‘crazed’ creepy enemy splicers that sneak up on you especially the ones that he has covered entirely in plaster that appear behind you and jump at you when you turn around. It’s almost like horror and mental illness go hand in hand in these types of games.
When you first encounter Cohen, he traps you in Fort Frolic and takes over your radio in the theatrical fashion that this trope is known for. He toys with you and then has one of his ‘disciples’ play the piano and blow up in front of your very eyes. Then he asks you to murder three of his remaining disciples all while taking part in snuff photography. All throughout, his paranoia and ‘insanity’ is obvious from the ensuant radio contact. Once these photos have been placed onto a quadtych, Cohen pretends to mistrust you and sends intentionally weak splicers your way, watching in elation as you kill them to the tune of orchestral music – all to create a grand entrance for Cohen himself who rewards you and allows you to leave unharmed.
What this does is paint a simplified narrative that people suffering from mental illness are violent psychopaths with absurd moral codes and a flair for theatrics. But this could not be more untrue. Only 3% of all violent crimes can be attributed to people living with mental illness. In fact, they are more likely to be victims instead as most criminals seek the weak and secluded as easy targets. Far Cry, Final Fantasy, Silent Hill and many more all subscribe to this trope as well. Perhaps they couldn’t foresee the impact they would have on society as a whole, but it is still not too late to remedy this.
Ethical Example – Persona 5 (Futaba Sakura, Futaba’s Pyramid)
In Persona 5, you play as the leader of the Phantom Thieves. A group of high school students tasked with ‘stealing the hearts’ of criminals by entering their subconscious – where their twisted and warped desires form ‘Palaces’ which can be entered and explored. Each palace is based on the twisted desire of their owner and is sustained by their cognition. At the very end of these palaces, lies ‘the treasure,’ which once stolen, forces the owner to have a change of heart in the real world.
This all changes when the Phantom Thieves are tasked by Futaba, to steal her own heart. Futaba Sakura is not a criminal. She suffers from social anxiety, depression and even PTSD-like symptoms. She is a reclusive shut in (or a hikikomori as known in Japan) that refuses to leave her room or even directly talk to other people.
Set in an endless desert, her palace takes the form of a pyramid and she a pharaoh. This pyramid is to be her tomb and she will die a lonely and deserving death here or so she believes. It is filled with tricks and traps to dissuade the thieves from progressing. And within the pyramid, each section of her mind is blocked out by a gate that can only be unlocked by unscrambling a memory of her past, until you discover the traumatic event of her mother’s suicide right in front of her very eyes. She blames herself for her mother’s death. Her memories seem to paint her as a child that threw a lot of tantrums, constantly annoying her mother, causing her mother a great deal of stress and pain, along with the voices that blame Futaba for killing her own mother.
You are then blocked by an impenetrable door, representing the door to her room in the real world. She must unlock this door herself (in the real world) and let the thieves inside. Only by facing her anxiety can her heart be stolen and so she reluctantly agrees but hides in the wardrobe after unlocking the door. The final boss guarding the treasure (a sarcophagus) is her mother in the form of a sphinx. She can only be defeated by Futaba herself entering the palace and facing the lie; for her guilt and cognition warped her memories of what happened. Yes, her mother would scold her for throwing tantrums, but she was also loved. She was not to blame for her mother’s death and only by accepting this can she awaken her Persona and fight back with her friends.
Fast forward to after defeating the final boss, etc. and you realize that Futaba does not magically get cured unlike the other characters whose palaces you visit, because you never truly steal her heart. The sarcophagus was empty, because Futaba herself was the treasure. With the support of people that care for her, she manages to pull herself out, initiating the first step of getting better. But it doesn’t end there, she creates a little list of things (a promise list - going to school, a public place, etc.) while using the main character as a ‘key item’ or a safe space to hide behind at times to fulfil this list. Only time and care can heal these kinds of wounds and the journey is both gradual and difficult.
Golden Rules for designing ethical mental health experiences
Based on the comparative analysis above, I propose 5 golden rules that could help in the design process of games that wish to tackle mental illness with responsibility and awareness.
Rule Number 1: Do your research and consult with both people living with a mental illness as well as mental health professionals.
Mental health is a relatively new field of research and new discoveries are made almost every day. Besides that, it is quite unique to each individual with a lot of people having different experiences. It’s important to use relevant terminology when representing something that has been so stigmatized and misrepresented in society that ‘crazy’ and ‘normal’ are considered polar opposites. Getting a broad range of perspectives is always the way to go and can only help the world progress to a kinder, more understanding society.
Rule number 2: Promote empathy, understanding and discussion.
Past approaches to mental illness have been terrible. Both in treatment and perspective, humanity has been found severely lacking. This ‘failure of humanity’ has only recently been addressed. However, the portrayal in games is still playing catch-up. The mental asylums, outdated Lovecraftian approach to madness and horror and the Homicidal Maniac Trope (as discussed earlier) has only led to a false sense of understanding and overall lack of empathy, where people associate mental illness with all the wrong ideas and stereotypes. It is important for games to spark the debate of what truly lies behind the veil of ‘mental illness.’ That is the only way that false assumptions can be corrected, and empathy promoted.
Rule number 3: Always include the social context. Don’t be afraid to show uncomfortable or awkward situations.
Without social interactions and the dullness of daily life, it’s hard to contextualize what a particular mental illness means. You’re left with an experience that exists entirely in your characters head. Showcasing the challenges that daily life and society pose to someone living with mental illness is what elevates the experience. These uncomfortable situations are key in understanding what it means to live your life with such a condition. A lot of mental health complications arise from people hurting other people. But support systems like family, friends and mental health professionals (aka people) are also what help cope and deal with such complications. We cannot remove the social aspect and expect our game to be an accurate representation of mental illness.
Rule number 4: Avoid creating walking archetypes – i.e. using mental illness as a defining trait.
We’ve seen in the example how Sander Cohen’s defining trait seems to be his artistic insanity. It is what guides all his actions and can be heard in everything he says. If change is to be brought about in the industry, then we require fleshed out and multi-layered characters that are not only defined by the mental illness they live with. Delegating such triviality to such a complicated issue is mocking all of human progress till this point. A simple start would be to avoid using ‘crazy’ as an easy descriptor and instead refer to the particular condition be it depression, PTSD, schizophrenia, etc. Of course, the key word here is ‘avoid.’ I don’t think it’s completely unethical to base a character’s approach to life on their current state of mind. However, currently, almost every game does this. So yes, it is a problem.
Rule number 5: Focus on who you’re designing for and use trigger warnings if necessary.
Game developers must always keep their target audience in mind while creating the experience. When tackling sensitive topics like mental health, it might be a good idea to take a step back and decide who exactly you’re making this game for and why. If it’s for people with no experience of mental illness, you must remember that people that do have the illness in particular that you are representing, shall also want to play your game. It is quite difficult to create a representation so perfect that it resonates with both groups. Hence why I think it is important to have a trigger warning or even a short message about your intention at the start to help contextualize your goals and not alienate the very people that live with the mental illness that you have showcased.
Case Study - Hellblade: Senua’s Sacrifice
Hellblade is a game developed by Ninja Theory, about a female Pict warrior ‘Senua’ who, after the massacre of her village and murder of her betrothed is plunged into the depths of psychosis. As a player, you experience these depths alongside Senua in an extremely personal experience through the use of binaural audio and phenomenal visual effects as you both seek out the answers to questions tearing your very mind apart. Let us now test these rules out against this critically acclaimed game that handled psychosis in a responsible and informed manner.
“Do your research and consult with both people living with a mental illness as well as mental health professionals…”
Ninja Theory can be commended here. They were in constant contact with Professor Paul Fletcher, a psychiatrist and Professor of Health Neuroscience. They also got help from The Wellcome Trust, a research-charity based in London that helped the team through connecting them with people living with mental illness as well as experts. They also helped in tailoring the experience to showcase a fair and well represented version. They incorporated a lot of what they found through research like the environmental illusion-based gameplay and puzzles as well as the voices in her head.
“Promote empathy, understanding and discussion…”
The design approach of using ‘her world through her mind’ and focusing on having the player project themselves onto Senua versus looking at just another video game character, definitely creates a very visceral and emotional journey. I think the game does a good job of promoting empathy for Senua. It also succeeds in promoting discussions about mental health and raises the bar on how games need to be dealing with it. I think this beautiful fan reaction trailer, sums up what people thought after playing, quite well.
“Always include the social context. Don’t be afraid to show uncomfortable or awkward situations...”
This is where the game seems to fall short. You’re only ever inside Senua’s head and except for one fascinating scene where Senua remembers back to the first time she met Dillion, there isn’t much direct interaction with other people. Like Dia Lacina says “It’s because of this lack of social context that Hellblade communicates (perhaps unintentionally) the harmful idea that mental illness “is all in her head.” It presumes a world where people with mental illness exist wholly divorced from their societies.” Unlike Persona 5 where Futaba is always forced into interactions with people and must learn to live with her anxiety, along with the help of her friends, Senua has no one. At the same time the game is not afraid to present the player with a lot of uncomfortable situations from self-harm to screaming close ups. You can also make the point that Senua was locked up by her father so she wouldn’t follow in her mother’s footsteps. Still I believe it to be a valid criticism and rest my case here.
“Avoid creating walking archetypes – i.e. using mental illness as a defining trait…”
This is a debatable representation. You don’t learn too much about the various motivations and interests of Senua because the game is so focussed on psychosis. You are somewhat left with a tunnel vision approach where again most of everything leads into her illness. In this case, it is a bit hard to avoid since mental illness affects different people differently, the effect psychosis has on Senua makes her journey feel both real and in her head at the same time. Like Jason Faulkner puts it, “If you took away the conceit that Senua lives with psychosis and replaced it with real demons, ghosts or dark magic, how different would the game be?”
“Focus on who you’re designing for and use trigger warnings if necessary…”
I believe it was quite clear that Hellblade was designed primarily for people with no background of psychosis to experience what people that live with it might go through and empathize with the challenges they face. It also includes a warning at the beginning as well as a link to more information about psychosis. As seen from the fan reaction trailer, a lot of players who live with/know someone that has psychosis were greatly touched by the game. And though it did receive some negative criticism like the ones mentioned above by Dia Lacina and Jason Faulkner. I think overall it does more good than harm and I hope more games follow suit and continue to improve the state of mental health representation in video games.
Conclusion
The undefined and stereotypical ‘insane’ characters seem to be the common element in games that handle mental illness in an unethical and irresponsible manner. Not only does this type of portrayal discourage the public at large from seeking further understanding, it also reinforces the idea that those who suffer from mental illness are broken, defective or otherwise ‘different.’ These characters are dehumanized, portrayed as mental disorders embodied and wrapped in ostensibly human packaging. Mental illness can never be perfectly portrayed as it differs for every individual that lives with it. However there exist games that tackle mental illness with clinical resolve and commit as few missteps as possible while maintaining the entertainment value of interactive media. Talking to experts as well as people who experience such illnesses is a great way to promote understanding and can lead to informed design decisions that encourage healthy conversation and create a game that has a strong impact on society and contemporary culture itself.
List of games that tackle mental illness
Either intentional or unintentional depictions that are not included in this article. I’ve tried to cover most mental illnesses, and even some other conditions that affect the mind. This is more of a compilation list, so I shall refrain from detailed descriptions:
1. Mindlight uses a biofeedback device and Cognitive Behavioural Theory (CBT) to reduce anxiety in children during stressful situations. Children are confronted by stressful in-game situations and must calm down to increase the amount of light and reveal the true nature of the event causing them such stress.
2. Child of Light tackles depression and grief in the style of a fairy tale with metaphors and friendship. It doesn’t really base itself in any obvious research or promote any serious discussion, but still puts it to good use as a sub- theme. Other games that tackle depression well are Please Knock on my door, Depression quest.
3. Knock-knock – while not directly stating any mental illness, the game seems to be looking at isolation and insomnia and its effects on the mind. However, it doesn’t really back itself up with any research and sort of falls into the walking stereotype scenario with insanity and horror as the side effects.
4. Concrete Genie is another game that doesn’t directly deal with mental illness, but rather the strain that bullying can have on a person’s mind. Built off the experiences from the developers, it isn’t really backed by any particular research, however it does offer a place for victims and perpetrators to think about their actions and how it impacts their lives. The gameplay also serves as a meditating space to paint freely and without judgement.
5. Spec Ops: The Line is an interesting take on PTSD, through the use of violence and the casualties of war as well as the progressive change in dialogue and loading screen messages. Alice: Madness Returns and Fran Bow while not perfect could also be considered decent examples of PTSD and psychosis in how they represent mental illness being a curse and a blessing, but more importantly something you have to go through daily life with, interacting with other ‘normal’ people who are quite clueless. Whereas Max Payne, could be an example of a fairly shallow portrayal of PTSD.
6. Mangia is a text adventure game created by Nina Freeman. It’s probably one of the few games related to eating disorders that I’ve played, and it tackles it in a fairly informed and personal way. High School Story, a mobile game from Pixelberry Studios had a campaign looking at body image in teenage girls with a story as well as external guidance. Consume Me, by Jenny Jiao Hsia attempts to deconstruct the rigid rules of diet culture.
7. Disco Elysium – this game deserves an entire paper on its own, but let’s just say it lets you converse in-depth with the various parts of your psyche, each with their own motivations and extremities. There is no filter to the potential of thought, and Disco Elysium elucidates that perfectly.
Sources
Mental Health by Hannah Ritchie and Max Roser (2018) https://ourworldindata.org/mental-health
Gaming With Stigma: Analysis of Messages About Mental Illnesses in Video Games https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707601/
Kelli Dunlap (2018) Mental Health in Games: 3 Design Tropes that Need to Die https://ithrivegames.org/newsroom/blog/mental-health-tropes-that-need-to-die/
Extra Credits (2019) Mental Health in Games - How We Can Do Better https://www.youtube.com/watch?v=hht0MtPZ_Ng
Emily Bulthuis - Mental illnesses: Terms to use. Terms to avoid. https://www.healthpartners.com/blog/mental-illnesses-terms-to-use-terms-to-avoid/
Vikram Patel and Martin Prince (2010) Global Mental Health: a new global health field comes of age https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432444/
Patrick Lindsey (2014) Gaming's favorite villain is mental illness, and this needs to stop https://www.polygon.com/2014/7/21/5923095/mental-health-gaming-silent-hill
Charlotte Cutt (2017) Futaba Sakura's storyline in Persona 5: the players' response https://www.destructoid.com/--438847.phtml
Dia Lacina (2017) What Hellblade: Senua’s Sacrifice gets wrong about mental illness https://www.polygon.com/2017/9/15/16316014/hellblade-senuas-sacrifice-mental-illness
Jason Faulkner (2017) Hellblade tries to show the real experience of psychosis — but ends up using it as a plot device https://www.mic.com/articles/183611/hellblade-senuas-sacrifice-mental-illness-plot-device
Ninja Theory (2018) Hellblade: Senua's Psychosis | Mental Health Feature https://www.youtube.com/watch?v=31PbCTS4Sq4
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