Representing Mental Health in Games


Hi everybody! My name is Dr. Kelli Dunlap. I am the manager of mental health research and design at iThrive Games and I’m really excited to be sharing my talk here on the representation of mental illness in games. So, a little bit about myself and my background. I earned my doctorate in clinical psychology and then immediately after that went into a master’s program for Game Design, like you do. Because the intersection of mental health and games is something that I’m super passionate about.
A few years ago there was a big uptick in conversations around diversity in games among games scholars, players, devs, and the industry over all these conversations about representation focused mainly on gender, race, sexuality, and ability to some extent, all of which are super important to be looking at and analyzing.
But it made me wonder about the state of mental health and mental illness representation in games. I quickly discovered that research on
representations of mental illness in games is pretty much non-existent and I could count the number of scholarly works on this topic on one hand. This was really surprising because research on portrayals of mental health and other media like film and television is pretty robust and spans over 40 years. This is not the case for games. The next thing I discovered was really surprising to me that mental illness is actually really common in games. So according to available research about 25 percent of games portray a mentally ill character. So that’s about 1 in 4 and by comparison in the United States where mental illness is roughly about 20 percent of the population or one in five.

So mental illness is more common in video games than it is in real life. And so I began to wonder since mental illness is so common in video games, what are those representations saying and what are those characters portraying? Mass media including TV, film, and games is the public’s primary source of information about mental health because mental illness is stigmatized and talking about mental health issues is still considered taboo. Media portrayals are frequently the only reference point people have for what
mental illness looks like. Imagine if the only exposure you had to say the opposite sex was what you saw on TV. It would be a very different experience than than what is actually the case. And this is probably why 30 percent of Americans still think that mental illness is a sign of bad character and why 46 percent of Americans think that someone with a mental illness is much more likely to be dangerous than a person in the general population even though a person with a mental illness is ten times more likely to be the victim of violence than
someone without a mental health condition. On top of that of all the
violent crime committed in the U.S., persons with mental illness comprise
only 3% of all of those crimes. So it is very very rare for for the some with a
mental illness to act out in an aggressive or violent way. How mental
illness is portrayed in the media also has a significant impact on persons
coping with mental illness themselves. Research has repeatedly shown that fear
of stigma is one of the most common barriers to treatment alongside costs and
access to mental health professionals. So the fear of being judged by others or
this self stigma around mental illness is just as powerful a dissuasion from
seeking treatment as the cost of therapy or having access to therapy. Based on the
available research, it appears that games are following the same pattern as TV and
film in how they represent mental illness as inaccurate, exaggerated, and
perpetuating harmful stereotypes. But because there is so little research and
because existing research has relied so heavily on film and television tropes to
identify and analyze mental health representations, the full state of mental
health and games is unclear. Previous research has spent a lot of time and
energy trying to categorize mental illness in games using categories that
were established for film and television. For example, of all video games, 70% of
mentally ill characters in those games fit the homicidal maniac trope — think
Hannibal Lecter or The Shining, for example. However 20 percent of portrayals in video games could not be put in a category. And that’s
really big. That’s a really large amount of representations to be otherwise undefined and thinking back to earlier in the
presentation — that 25% of characters — that paper actually only looked at characters
and did not account for other mental health portrayals such as sanity
meters, psychiatric hospitals, and language like depressed, OCD, or psycho.
It’s important for us to capture this full spectrum of mental health
representations before we can begin to analyze them. In order to do that, I have
developed a spectrum of psychopathological representations in
games, which is a title I’m hoping to get maybe a little bit snappier in the
future. To do this, I developed the dimensional representation of
psychopathology in games and I based this spectrum on approach on mental
health disorders in the DSM, the Diagnostic Manual for Mental Health
Professionals. The goal of the spectrum is to write a standardized framework for
researchers to identify and analyze mental health portrayals in games. The
spectrum features three main clusters of dimensionality — one, two, and three
dimensional representations of mental illness and games. So we’ll start with
one dimensional representations; one dimensional representations are broad
references to mental illness wherein the representation is a non-essential
element to a character, story or environment. One dimensional RP portrayals acknowledge that mental illness is something that exists in the world,
but only through passing reference. So for example this is Heimskr. He’s a Nord priest in the Elder Scrolls game Skyrim and he preaches outside the
keep in Whiterun, which is very popular city in Skyrim, and he is regarded by
the town’s folk as being mentally ill. NPC’s in the city actually referred to
him as being quote-unquote “crazy,” but labeling Heimskr as crazy is not essential to any aspect of the game. And if it were never alluded to it all nothing would change. So this is a way of signaling there’s something odd or off about this person. Because we’re calling him crazy but it really doesn’t have any more deep meaning than that. example is the mental illness in name
trope wherein characters names presuppose the presence of a mental
illness, like the “psychos” from Borderlands, “Crazy Red” from Animal
Crossing: New Leaf, and the disturbed suspect from L.A. Noir. Naming these
characters does nothing in terms of the story or character development, other
than signal to the player that there is something odd about the character or the
situation and could be removed without anything related to the character
narrative or setting being lost. However, one dimension is not inherently bad
or negative. For example, an NPC could mentioned in passing that she went to
therapy, or perhaps in searching a house a player could find a prescription for
psychiatric medications or psychiatrist business cards. These kinds of neutral
non-stigmatizing references may even be helpful as they normalize the presence
of mental illness and its ephemera in mundane everyday life. Next up are
two-dimensional representations and these are portrayals of mental illness
and psychopathological features that are essential to or are a defining element of a
character, story, or setting, but they lack any kind of depth or dimensionality. In
other words, the game does not extend to explore mental illness beyond the very
surface level. For example, in Final Fantasy VI, Kefka, the game’s main villain, is motivated to destroy the world solely because he is quote unquote “insane.” Similarly Vaas Montenegro from Far Cry 3 and Makarov from Call of Duty Modern Warfare also have extreme violent tendencies and delusions of taking over the world and it’s all attributed to this very vague idea of insanity. This psychopathology that they have is core to who they are as characters. And if you removed it they wouldn’t be characters anymore. They would just be, you know, a hollow shell of a character. There’s nothing deeper going on. Similar to one dimensional representations, two dimensional representations are neither inherently good or bad. For example Sandal from Dragon Age Origins appears to have a cognitive impairment that renders him pretty much mute and it is strongly implied that Symmetra from Overwatch is on the autism spectrum. These characteristics are important to each character — identity in Sandal’s case, or personality in Symmetra’s case. But these components are not explored, questioned, or discussed yet they are critical to who these characters are and what they can do. It’s crucial that these kinds of neutral representations can be included in assessments of mental illness
representation. Otherwise researchers may overestimate the percentage of
portrayals that are over the top or that propagate negative stereotypes or are just
the easiest to identify and categorize, which tend to be the ones that are the
most extreme and exaggerated. These representations also serve as a model
for game developers on creating characters with mental illness symptoms
in a neutral or non stigmatizing way. And last up, are three-dimensional
representations. Three-dimensional characters, narratives, and environments
are more than just plot points or convenient backstory. They are essential
and fully realized components. These representations have depth and
dimensionality and examine the experience of mental illness from
multiple perspectives. For example, two prominent games that do this very well
are Hellblade by Ninja Theory and Town of Light by L.K. Both games feature character narrative and environmental representations of mental illness and deliver thoughtful and emotionally engaging stories that explore the depths of mental illness without stereotype sugarcoating or being mental health tourism. Both games also draw extensively from real world sources. Hellblade was developed in cooperation with mental health professionals and individuals who had experienced psychosis or voiced hearing —
so experts by lived experience, and Town of Light is based upon historical
documents and places. Three-dimensional representations do not need to be true
to life in terms of narrative or design, but they do need to reflect authentic
experiences. Neverending Nightmares and Night in the Woods are two great examples of this. Neither game is realistic in terms of graphic fidelity the to the real world and the story told in each of these is fictional. But the gameplay creates both the cognitive and emotional experiences that are multi-dimensional complex and reflect an experience that is authentic and genuine. So all this is to bring this to my
my goals and hopes and dreams for this this framework. I want to be able to
capture all the ways that mental health is portrayed in games and so researchers
have a standardized foundation for collecting, sorting, and analyzing
portrayals of mental illness in games that is unique to games. Games are not
like other mediums and they really deserve their own framework and
foundation. I also want to raise awareness about how common it is that
mental health and mental illness issues appear in games and the casualness with
which it’s often treated. Raising this kind of attention can do a lot to help
stem stigma or confront these kinds of stereotypes that are so common
throughout all media. And last but not least I want to help game devs think
critically about their decisions to include mental health representations in
their games. So this is not to say that every portrayal has to be a
three-dimensional representation. Skyrim wouldn’t be a better game if it
included a side quest that involved going into Heimskr’s psyche and
background and to really understand where this idea of insanity comes from.
But it is useful for game developers to think in this context so they don’t
shortchange representations of mental illness when it arises in their games. It
is totally acceptable to have a one or two dimensional portrayal but having
this on the spectrum gives developers a framework for creating non-harmful
portrayals by encouraging them to ask themselves, “does this serve our purposes
without propagating harmful stereotypes?” And that’s it! Thank you so much.

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