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The Royal College of Psychiatrists Improving the lives of people with mental illness

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02/01/2018 11:50:05

This War of Mine – a game about the traumas of war

This War of Mine title screen

Here at Gaming the Mind we particularly appreciate originality in games, both in form and content. A firm favourite is Life is Strange, with its rewind mechanic that allows experimentation with social communication within a world that is admittedly ‘strange’, but also in many ways familiar and ordinary. Some games, however, provoke emotions and reflections that allow us to empathise with people experiencing lives that are very different to our own. If this sounds a bit farfetched, try out the decision-making mechanic in Papers, Please, where your family’s life and the lives of refugees are hanging on the choices you make. Or try surviving the long days of This War of Mine, a game about staying alive in a war zone as a civilian.

This War of Mine is about choices, prioritisation and risk taking. It’s about luck, discipline and planning, and it’s about not giving up. Now, if this sounds serious and not particularly fun, well that’s just how it’s supposed to be. The game is bleak; it fills you with hopelessness and is deeply depressing. In this game about war, you’re not the omnipotent hero; you’re the little person getting rained down upon. I’m not going to say it’s realistic, because thankfully I’ve never experienced war, but it’s a simulation of an experience that many civilians in war zones endure. And it gets you in ways that a film couldn’t, because you’re actively involved in creating the story and the outcome.

11 bit studios, who made the game, drew influence from the 1992 Siege of Sarajevo, which lasted 1,425 days and led to 5,434 civilian deaths. They used first-person accounts from the FAMA Collection, a media project that collected oral histories from people caught up in the conflict in former Yugoslavia, to create a realistic game world with real-life challenges. This attention to authenticity, both within the narrative and the gameplay itself, avoids what has become known as “ludonarrative dissonance”– a critique particularly aimed at war games that attempt to portray a moralistic view of the horrors of war whilst ironically rewarding senseless violence.

As the player, you look into the cross-section of a bombed-out house, with its dark basement, bare kitchen, rubble-strewn upper floors and broken roof. You direct three characters by clicking on objects to interact with, such as a cooker, a fridge or a bed. After scavenging for resources, you can build things that help your characters survive – a water filter; a radio; a weapon. In this game, you can kill and be killed, and there are no extra lives. This is no obscene undead pre-oedipal fantasy, as Slavoj Žižek likes to call the immortality mechanic in video games. When your character, who has a name, a face and a personality, dies, she’s not coming back. This game is about loss.

A cross-section view of the survivors’ dwelling

A cross-section view of the survivors’ dwelling

War is hell; hell is other people. You’ll find that you need the help of others to survive this game. You’ll need to learn to barter with the random strangers who come to your door unannounced and you’ll need to learn to exploit your team members’ strengths and keep them strong, through cooking and sleeping and guile. The game offers you the chance to play with a total of 12 different groups of characters, with each group having different stories, starting environments and resources. This leads to interesting variations in tactics and choices. Each night, you get the opportunity to assign your team members roles such as being a lookout for raiders, a scavenger in the local area or the person who gets some precious sleep. The scavenger missions involve directing your character around unfamiliar buildings filled with dark spaces, bounty, and strangers who are often homicidally unpleased to see you. You might assign the most physically strong or fast character to venture into the night, but even they require regular food, rest, and, if injured, medical assistance.

Characters must care for themselves and each other

Characters must care for themselves and each other

Mental health themes run throughout this game, as you would expect from a game about war trauma. Loss is certainly a feature, as are constant threat and fear. The game is clearly trying to give the player the experience of living in an extreme environment where bad things can happen on a daily basis and where you have very little control over your life. A lot seems down to luck and the game is often deeply unfair and mean. Some characters show incredible levels of resilience whereas others don’t.

Characters have moods which respond to various factors; for example, their mood will deteriorate as they become involved in, or are exposed to, traumatic events, witness suffering and death, or endure hardships such as hunger, illness or injury. Eventually a character can become depressed, and unable to engage in daily activities; even those that aid self-preservation. It is possible that characters may end their own lives if they remain in a severely depressed state.

However, their mood can recover through actions such as engaging in good deeds, eating well, sleeping well, and having access to entertainment. Importantly, characters can console each other to help improve mood, which highlights the importance of reaching out to others when in need. A custom psychologist character is especially skilled at consoling others, sending a clear message about the importance of seeking the attention of mental health services when unwell.

One character attempts to console another to help lift their mood

One character attempts to console another to help lift their mood

Of course, this presents a basic view of depression and recovery. Consoling is depicted as simple conversations between characters, with phrases such as “I’m here for you, if you need me”. It seems logical that in this crisis scenario, things such as food and sleep could reduce stress, but depression and post-traumatic stress can often present with sleep difficulty and loss of appetite, so presenting these activities as generalisable solutions to low mood or trauma in all contexts would be overly simplistic and narrow. However, if taken as encouragement for players to engage in self-care, and to seek help when needed, the game’s message rings true for our daily lives. If the game teaches us one thing, it’s that to survive we depend on mutual aid and cooperation.

As I write this, a number of cities and towns remain under siege and at war. This game is important because it makes it that bit harder to forget what war does to people.


This War of Mine is available for Windows, OS X, Linux, Android, iOS, PS4 and Xbox One .

Authored by Stephen Kaar

31/10/2017 15:21:30

Depression and the daily grind: Michael Levall on his game Please Knock on My Door

When I sat down to speak to Michael Levall, the Swedish main developer of Please Knock on My Door, my first instinct was to tell him that I enjoyed the game. On reflection, I wondered if ‘enjoy’ was the right term to use for a game about depression. Levall saw this as an issue with how games are typically perceived. “There are books that are not supposed to be strictly fun,” he said. “There are movies that deal with very heavy things, and I feel games have this idea connected to them that they are supposed to make you laugh, but I don’t think that’s the case at all.”

Michael Levall

Michael Levall. Photo: Kristian Andersson/Commersen

Please Knock on My Door focuses on a fortnight in the life of a character who experiences symptoms of depression. It’s a down-to-earth tale, with the player seeing the main character through everyday tasks at work and at home. In portraying this, the game shows how deepening depression can affect daily functioning.

Initially a prototype he had developed at university, Levall’s game was inspired by his own experiences. “I wanted to use the game medium as someone else would use a diary. When you use a diary, you write with the purpose of having a moment of reflection. I decided to use game development for that same purpose.”

He returned to the prototype three years ago to begin development proper. The writing process for the game was stressful, at times. “I would write late in the evening. I would prepare myself mentally for an entire day just to get a couple of hours of writing done. I have a ton of respect for the subject matter, which means that I would rather release nothing than release a game that deals with this poorly. So it was very important for me to make sure all of the texts were serious, genuine and respectful to the subject matter and to people who had similar experiences.”

The scenarios within the game offer a candid view of the trials someone with depression can face. “I had done the initial prototype when I was depressed,” Levall said. “That was a way for me to cope and to deal with what I was going through. Many of the stories I wrote for the game are actually taken from my own life.” On top of this true-to-life foundation, Levall elaborated with fictional elements, as he “didn’t want to create an autobiography in game form.”

As a result of Levall’s perspective, Please Knock on My Door is a particular take on depression that won’t necessarily ring true to all people. “I felt there was some higher value in the player being forced into this specific narrative that followed only one person and their struggles. As long as there are parts of it you can connect with, you can still empathise with the main character.” Levall resisted taking a broad view in order to preserve the ‘soul’ of the game. “I don’t think you can generalise too much. If the game was entirely relatable to any other person, would it still be personal?”

However the game resonates with players, Levall intends for the game to have a wide appeal. “One core idea was that I wanted someone who was depressed to be able to use the game as a catalyst for discussion, essentially offering the game to a family member or friend and going ‘Hey, I can’t explain what I’m going through, but if you play this game, maybe you’ll be able to understand, and we can talk.’”

Please Knock on My Door

Making the main character gaze out of the window brings emphasis to his isolation

Central to the game is the main character’s “mental fortitude”, a measure that isn’t explicitly explained, but might be thought of as a summary value of the character’s mood, energy, motivation and confidence. As this value decreases, the player becomes less able to engage in certain actions. The first actions to become unfeasible involve communicating with others. As the mental fortitude continues to dwindle, even simpler tasks become impossible to complete. “I wanted to convey that when things are going your way, you’re able to deal with things and talk to people about how you’re feeling, but when your mental state declines, all your effort goes into, for example, being able to do the dishes.”

Almost every action in the game has either a positive or negative effect on the mental fortitude value. “It is a way to make the player explore how their actions affect the mind state of the character,” said Levall. “If you don’t eat, if you don’t sleep well, if you don’t talk to people, that’s going to have its effect on you.”

Some actions can have different effects in the short term compared to their eventual long term effect, as Levall explained: “I made that to show that some things can make you feel worse at the moment, but they can have positive effects in the long run. For instance, facing difficult thoughts or talking to people about difficult things; those might be difficult to do, and might make you feel worse in the moment, but can increase your mental state going forward. In the opposite way, if you use games as escapism, or watch TV shows to avoid dealing with life, that might make you feel better for the moment, but in the long run that’s only going to bring you down.”

Please Knock on My Door

Television is a momentary comfort, but can invite negative thoughts and ruminations

Levall is open about the fact the game stacks the odds against the player. Maintaining mental fortitude is difficult, and all the more difficult when you can’t do things that might be helpful, such as reaching out to others. “I wanted players to always feel the weight of every choice,” he said. “I get the sense that most people feel like there’s something that they could do, but they simply can’t figure out what that thing is, which to me is one of the central emotions when you are depressed. You feel like there should be something for you to do, like you should be able to deal with this, you should be able to snap out of it, but it’s just impossible.”

The main character bounces back and forth from home to work, but as depression creeps in, it becomes difficult to maintain this routine. At home, it is up to you to pass the time, which can be hard when there is little your character wants to do. “One thing I felt was a common thread for people with depression, and that resonated strongly with me, was that hobbies stopped being fun or interesting. For me, that meant playing games in the evening wasn’t something I did for fun, it was something I did to pass time, because I wasn’t tired enough to go to sleep. I wanted that to be part of the game.”

If passing time is hard, equally hard is keeping to time. You need to leave for work in the morning, but with a growing tendency to oversleep, and a morning routine that can take longer than anticipated, chances are you’ll eventually show up late to the office. “In the game, you don’t get to decide how long actions are going to take you,” said Levall, “because you don’t sit down to watch TV and decide exactly how many minutes you’re going to spend there. Of course that has implications during the morning ritual, like do you have time to eat? What kind of food should you make? Do you have time to shower? Should you just take a quick shower? That information on timing isn’t there; it’s all hidden. I wanted to capture the sense that you merely push the character in certain directions, but you’re never in complete control, just like you’re never in complete control in reality, either.”

It shouldn’t come as surprise that things begin to spiral out of control, both at work and at home. If you are used to feeling rewarded by games, this might be tough to take. “It was actually very difficult to write in a way that the player wouldn’t just get frustrated,” said Levall. “How do you write a character that has weaknesses that don’t come off as frustrating for the player? Usually that’s a no-no as far as games go; you want the player to feel powerful and in control.”

The game creates an excellent tension between the mindsets of the player and the character they are playing as. For example, it may seem obvious to the player that the character should cook and eat a comforting meal, but that may be beyond the character’s capability. Similarly, at work, the player may notice social support is available that the character isn’t able to appreciate. “In this case, I had to write characters that would give enough hints so that the player would know ‘Okay, these characters care’. They try to reach out to the main character, however they still have to be obtuse enough for it to make sense that the main character, in the state they are in, would not be able to understand or would not have the energy to pick up on it.”

Please Knock on My Door

Cooking, eating, and washing up are daily chores that become harder to maintain

As the game draws to a conclusion, things become increasingly desperate for the main character and their ability to cope. How things turn out depend on the player’s choices, with three possible endings. There are no ‘good’ or ‘bad’ outcomes, with all endings operating on what Levall labels a greyscale. Of course, one outcome is worse than the others, and I had to ask Levall about this. “Personally,” he replied, “I didn’t want it to be too obvious a thing. Think: what could be the most horrendous thing to happen in response to depression? Of course, suicide comes to mind. I didn’t want people to expect that to happen, and for me to just give in to those expectations. But, at the same time, if I didn’t deal with that, would I still be doing the theme justice? I decided to keep it in, but with my own twist to it. I feel like the most important thing is to be honest and upfront with players, so that someone who does not want to be subjected to that would not be shocked. I wanted to be very upfront with players about what this game is, so that they don’t expect this game to be something else.”

Such themes can be distressing, but Levall wants players to see the hope in each ending. “I never wanted to leave the player in a dark place, so I usually tell people to not stop playing once they start. The second week pushes the player very far down, but I wanted to leave the player with an idea that things get better. That was very important to me. I feel some responsibility as a creator that if someone who is depressed plays my game, I don’t want to leave them feeling like everything is hopeless, so it was very important for me to make sure all of the endings had some kind of positive connotation to them.”

Like many games that tackle the subject of depression, the prospect of seeking medical attention is not covered. While Please Knock on My Door touches on themes of recovery, Levall is clear that he wasn’t producing a guide on how to get better. “I’m not a psychiatrist, so I don’t feel comfortable talking in those terms,” he said. “All I could do was to try and offer an individual perspective and hopefully add something valuable to the overall discussion about mental illness. I can’t say for sure if someone who is depressed would gain something from playing this; I have heard from people that the game was able to strike a chord with them. In the end, I made it more as entertainment than as a tool, but I feel entertainment has a strong place in our culture for dealing with difficult themes and making them more available and approachable to people.”

While Levall is keen for Please Knock on My Door to contribute to the conversation on mental illness, he recognises that encouraging people to play it remains a hurdle, once again striking on the idea that games should be only for enjoyment. “One of the bigger challenges has been to convince people that the game is actually worth their time. As it is a commercial product, people are choosing between this and whatever other game is made for them to feel happy. So it can be a bit of a rough sell. The way I try to frame it is that this game won’t simply last two hours and be over; hopefully it will give you some kind of a takeaway that you can then bring with you during the rest of your life. I feel it has been able to do that, at least for some people.”


Please Knock on My Door is currently available for Windows.

Authored by Sachin Shah

25/07/2017 09:58:55

Dr Hugo Spiers on Sea Hero Quest: the game which uses play data for dementia research

Dr Hugo SpiersDr Hugo Spiers

Sea Hero Quest (SHQ) is a free game available on Android and iOS, which collects data on how players navigate its wayfinding tasks and then uses this data as part of dementia research. Amazingly, it has translated 73 years’ worth of gaming activity from 2.7 million players into the “largest dementia study in history”, and so I was excited to speak to Dr Hugo Spiers (Reader in Cognitive Neuroscience, University College London Institute of Behavioural Neuroscience), who is leading this research.


Creating a diagnostic tool for Alzheimer’s dementia

The game tasks the player with navigating in a boat using simple left/right controls. Data from players will show how well they use spatial navigation, and on a larger scale will show how spatial navigation ability differs across various demographics, including across ages. With this vast bank of general population data, the team are taking the first step in developing a tool to detect signs of dementia, by understanding what normal spatial navigation behaviour is, and what is pathological.

The initial levels of SHQ feel more like tutorials. These levels serve a purpose within the study, explains Dr Spiers: “We’re not tapping into the brain areas that you need to find your way... you are just going to a visible target and that allows us to effectively measure how fluent you are with these types of video games.” A seasoned player would reach the target faster than a gaming novice. This allows the team to understand how experience with gaming impacts on the player’s navigation skill, and to account for this in their analysis.

Sea Hero Quest - The player must navigate through the checkpoints in order The player must navigate through the checkpoints in order

The team can use mathematical modelling to assume everyone is bad at videogames, “and you still see a decline... just the steepness of the slope is much shallower because they start off performing badly in their early age group; they’re already poor navigators, but it’s exactly the same relationship between age and performance, it’s just the angle of the slope has changed because your starting point is different.”

There are plans to trial the game with an orienteering team, to see how their performance in the game relates to real-world performance. “It might show that there are certain levels that seemingly, for some reason or another, allow you to predict the best navigation performance in the real world. Or certain bits of those levels in breaking them down.” This will help the team in honing a more precise diagnostic tool.

The team have already presented preliminary findings; perhaps most notable is that spatial navigation ability as captured by the game appears to deteriorate with age from the early 20s onwards. These findings were based on two month’s analysis of a set of levels that tested the player’s ability to know which direction they had travelled from. There are more findings to come as the team sets to work analysing data on how the players actually navigated around the wayfinding levels. “As soon as you go to the tracking in the main wayfinding levels, we have a 500 millisecond resolution of where people were and what direction they were facing,” Dr Spiers notes. “It allows you to look at their choices in the topological network of paths; it allows you to look at how much they are deviating from the optimal path.”

Yes, there are people in the general population who happen to be bad navigators. But the wayfinding levels should give enough navigation data to tease out specific differences in navigation ability which may indicate deterioration due to dementia. “Something we have from the clinical literature is that people with dementia are more likely to just keep going forward than to take a left or right turn,” says Dr Spiers. “It might be that you have healthy bad navigators who just make lots of bad choices. But then you maybe have someone who’s got early stage Alzheimer’s dementia, and they literally just go forward into the wall and they don’t deviate in their path… the way they move is very different, diagnostically.”

Dr Spiers notes that most cognitive exams for dementia that have a lot of precision are language-based, which makes it hard to equate them across countries. “Plus, the clinicians I speak to aren’t really convinced that Alzheimer’s dementia is a verbal memory problem… patients are actually quite good at verbal memory, early on in the disease.  But they get lost: that’s why they typically come in to the clinic.”


Gaming as a research toolI had made it to level 40 of the game by the time I had spoken to Dr Spiers. With around 30 minutes of game time clocked, the game told me I had contributed two days’ worth of research data to the project. This was quite astonishing to me. Dr Spiers explained how this was the case. “We optimised the game in a way we hadn’t done before to collect this this really detailed trajectory data, so you couldn’t normally use the trajectory at that level, every 500 milliseconds. It wouldn’t be that meaningful in a small sample, but because you’re contributing to a very large sample it means every 500 milliseconds we’re getting very useful information from you. But if you were coming to the lab… to do this in the lab setting is just ridiculous; it’s not possible.”

Dr Spiers considered how other fields of mental health research could benefit from this form of study. Movement monitoring may prove useful for people with recurrent depression. For example, someone with severe depression is less likely to leave their house. But before they reach that stage, there may be more subtle changes that could be picked up. "The patterns in which they move through the space around their community before they stop leaving home might be predictive of a future onset of severe depression. So there’s potential in data on that which would be interesting to look at.”

Sea Hero Quest - The player relies mainly on their recollection of the map for direction The player relies mainly on their recollection of the map for direction

While SHQ isn’t looking at players’ real-life movements, the team is learning a lot about how they can analyse trajectories, which is the bulk of data they get from the game. "People vary enormously in what routes they take and it’s quite possible we could explore how people with depression change the way they move within the game.” 

When it came to designing the game, Dr Spiers found the team having to compromise between gaming and science. He’s pleased the game has received generally positive reviews on the app stores. “I thought if we’d not achieved that, it’d be a disaster because the fun game component does relate back to the science: if it’s not a fun game, you’re not going to get 2 million people playing it.”

There were also compromises made in the game design in order to fit the needs of the experiment. “If it had been a raw experiment, if someone was coming into my lab, they would have spent five minutes filling out a load of demographic questions. If you’d started the game online with five minutes of demographic questions, our sample size would be a thousand, because nobody would want to sit and answer a load of personal questions about their life before they get into the game, it doesn’t work like that on the app store.” Instead, the game asks only nine demographic questions about the player. “As a scientist, we needed to really work hard to get the best questions into the game. But we always knew it had to be done carefully, as a compromise, asking 9 rather than 90 questions.”

Dr Spiers foresees a rise in the use of games in research and gamifying experimental data input. “It is really good… It’s not typically seen to be worth it, whereas every experiment I make in my lab, I try to gamify it, so it is engaging, because I believe that you want people at their optimally engaged for your experiment… There’s some experiments where I think it’s just not going to be worth it. But I think in things that we’re interested in (navigating environments), you do want to bring people up to a situation that they’re familiar with: which is generally gaming.”

With millions of people playing video games in their free time, there is clearly great potential here for gathering data on playing activity for cognitive behavioural research, from players who agree to participate in such research. As SHQ has shown, the data acquired can be huge and detailed, which can provide new insights into population behaviour. It also lowers the barrier for people to take part in research, making it easy for people to participate from their own gaming devices. With the study involving SHQ already showing fascinating preliminary findings ahead of deeper data analysis, the field of gamified behavioural research seems to hold a very exciting future.

Sea Hero Quest is part of a research project that is a collaboration between Alzheimer’s Research UK, University College London, University of East Anglia, and the UK game development team Glitchers.

Authored by Sachin Shah

23/06/2017 14:53:05

A fantasy based in reality: how service user and specialist input informed the portrayal of psychosis in Hellblade

Recently a targeted advertisement for a video game came across my Facebook feed. Usually, most games I’m told to buy, to my shame, are Candy Crush and their ilk. This advert, however, was slightly different, featuring a behind-the-scenes glimpse of a game; the video was titled “Myth and Madness”.

A game that dealt with ‘madness’ as a theme? I watched the video with trepidation, worried that the game would resort to the “villainous lunacy” trope so often seen in entertainment media. However, after watching it, I felt that the video game developers were not merely paying lip-service to the issue of mental illness, but had invested time and energy into researching it.

The game was called Hellblade: Senua's Sacrifice. Hellblade is an action-adventure game that tells a story of a Celtic warrior named Senua, who is on a vision quest to retrieve the soul of her sacrificed lover. The story is told from the viewpoint of Senua, who experiences psychosis in the form of hallucinations and delusions.

With Senua as the protagonist, the game promises a “strong character story”


I was fortunate enough to be able to interview Dominic Matthews from Hellblade’s development team Ninja Theory (where he holds the enviable title of “Product Development Ninja”), about Hellblade and the psychiatric themes the game would cover.

Ninja Theory have a good reputation for developing well-rounded, aesthetically-pleasing, action-heavy games. Their reboot of the Devil May Cry series (retitled to DmC: Devil May Cry) critiqued modern consumerist culture, whilst their previous game Enslaved: Odyssey to the West was praised for its mature narrative. Hellblade is Ninja Theory’s first step in creating a game as an independent developer, free from mighty-publisher constraints.

Dominic described how Ninja Theory chose to cover mental illness as a theme. “This is our first independent game, so we have been fortunate to find ourselves in a position where we are able to make a game that we can control creatively. Without creative restriction, we wanted to do something unique and special, and that’s how we came across this topic.” The prospect of covering mental illness had clearly struck a chord with the developers. “Although it is not something we talk about overtly, this is a subject that is close to a lot of people in the team. We felt that it would be a great opportunity to make a video game and tell a compelling story, which we can develop.”

Dominic stressed that the purpose of Hellblade, a work of entertainment, “isn’t primarily about raising awareness or necessarily being educational.” However, within this entertainment medium, Ninja Theory have the opportunity to deliver a strong social message. “I think there is a lot of stigma attached to psychosis and to mental health difficulties. Exposure will ultimately lead to understanding. And the understanding will lead to destigmatisation.”

Brutal combat, a hallmark of Ninja Theory games, is of course present


Through their development process, Ninja Theory became involved with the Wellcome Trust. The Trust has a team dedicated to supporting entertainment and art projects that engage a wide audience on scientific themes, and has supported the Hellblade project through their Public Engagement Fund. “So we first met them,” Dominic explained, “and started discussing the project. We first got the development grant which was something that helped us to put together the concept, and now we are partners in co-production, so they have a financial grant into the project and that grant is helping us both deliver the game and make sure the scientific theme, in our case psychosis, is portrayed in an accurate manner.” Through the Trust, the developers were linked up with mental health service users as well as clinicians, including Paul Fletcher, Professor of Health Neuroscience at Cambridge University. “Through that, we have been able to make this link through art and its creative side and the scientific community and the service user community.”

Our discussion moved to how mental illness had been portrayed within video games in the past. “I think games have not always done a great job of tackling sensitive subjects,” said Dominic. “There is a whole number of areas where games have tried to tackle mental health. Sometimes they can reduce experiences of psychosis into gameplay mechanics; games with a ‘sanity meter’, which goes up and down. That is a very mechanical way of representing psychosis, and people’s perception of psychosis is very binary: ‘there is me and there is the person with psychosis’. Instead, what we have learnt through our work with Professor Fletcher and the Wellcome Trust is that psychosis is based in how we all perceive the world, the way we perceive our own reality, and how we all have different interpretations of our reality. What we are trying to do in Hellblade is present our character in a very truthful manner. I think in the past games have not necessarily done that.”

Eternal Darkness (2002) used a ‘sanity meter’ as a blunt measure, with depleted ‘sanity’ resulting in hallucinations


Ninja Theory is actively trying to move away from a mechanical representation of mental illness. “We created fantasy games for the last fifteen years, and in many ways Hellblade is the same. In the case of this game, the fantasy is the creation of Senua’s mind. So I think what people will experience in the game would be a unique experience that would have root in people’s real experience of psychosis and the scientific foundations behind it. It is part of the story; it is part of the character. Just like how we are our own characters, she is another character who happens to experience psychosis.”

Considering the way mental illness has been portrayed in video games up to this point, naturally there are concerns about how the concept can be reduced to a gimmick within narratives. “Mental illness is very much essential to the game,” Dominic reassures. “It is a story about a character on a journey; a quest where she happens to experience psychosis. So it is very embedded into the game; it is not something that is a twist at the end. It is something we are very upfront about. As the player, you will experience the world just as Senua does. You will experience the world through the visions and the voices that she hears, as well as other unique experiences.”

I wondered about the balance of creativity and clinical-accuracy in this game, and whether there had been any compromise in either direction. “We have worked with the academia and people who have experienced psychosis,” said Dominic, “and a wide range of different people who may just hear voices or people who may have unique beliefs which dominate their lives. It has always been important for us to do our research in the subjects we are portraying. But I think that working with Professor Fletcher and Professor Fernyhough (Charles Fernyhough, Professor of Psychology at the University of Durham) allowed us to understand the latest scientific thinking regarding psychosis and exactly how it manifests, and then we tried to represent that in the game. I think a lot of game developers, when they think of collaboration with science, they might think that science could restrict their creativity, but in actual fact it enriched our creativity. So many concepts, ideas, and experiences that people have come across are in the game, and it is much more compelling because of that input.”

The links that Ninja Theory made were useful beyond the bounds of professional game development. “On a personal level,” said Dominic, “and for many other people on the team, having the opportunity to not only speak to people who are experts in this field, but people who actually have these experiences, it has actually been very, very valuable. And it is something which we would like a lot of people to do: to sit down, and speak, and to understand.”

Dominic expanded on the team’s experience working with service users and clinicians.  “We were very up front about the mental health part of the game when talking to clinicians and groups, but we really didn’t know what the reaction would be, because historically video games tackling subjects about this have not been great. But we had a lot of support. Working with the service users has been fantastic. They have been very supportive and I think they enjoyed the experience of working with us in trying to manifest some of the things that they experience.”

“It has been great to talk to them, hear about the things they experience, to then translate that into the game world and show it back to them and see their reactions. And with a lot of things we tried, they said ‘Yes, yes,’ that’s very close to their experience. I think it has been a very fantastic collaboration. Also, I think having the opportunity to talk to us about those experiences is a different context for them. This isn’t a clinical context talking about these things, this is a context of creating entertainment.”

Senua must undergo a journey as the game progresses


I often find, when mental illness is depicted in media, that there is not enough emphasis on the types of help available, and people with mental illness can be shown as suffering with no means of support and no route to recovery. I wondered how Hellblade would portray the main character managing her experiences. Dominic noted that the game has a historical setting (so presumably effective treatments don’t yet exist in this world), but he also stressed that we can expect Senua to progress along with the story. “I don’t want to give too much away, but it is not only a journey with Senua, but also a journey with her experiences. It is a difficult journey, but it is a journey of understanding.”

With Hellblade, the developers Ninja Theory are taking a bold step into independent games development without the backing of a large publisher. Dominic was excited about this prospect. “If we were creating this game as a big blockbuster title, we wouldn’t be creating this game the same way we are, with this collaboration with the scientific community that we're working with. We get to create the game we want and get to grasp interesting opportunities. There is a lot riding on this game for us because we want this game to be the first of many... so there are risks there for us but we are definitely enjoying this challenge.”

Dominic’s team feels well placed to deliver a meaningful representation of psychosis to players. “Our aim with the combination of technology and creativity is to try to make it feel as close to the real experiences as we possibly can. It is a compelling thing, and I think when you lay on top of it that this is something that people live their lives with, we have the opportunity to help people understand a bit more.”

The film industry has produced works of entertainment that take steps to promoting understanding of mental illness, and this could potentially be a role within the video games industry. The initial groundwork of involving service users in the development process shows that Ninja Theory have taken a more inclusive approach to incorporating the experiences of psychosis that many people in society have. It suggests that we may be looking forward to a more subtle and accurate depiction of mental illness, and I am looking forward to seeing the outcome upon the game’s release.


Authored by Sin Fai Lam

Hellblade: Senua’s Sacrifice releases on August 8th for PlayStation 4 and Windows.

26/04/2017 11:57:47

Mark Saville on how SpecialEffect “levels the playing field” for people with physical disabilities

No man is an island,
entire of itself;
every man is a piece of the continent,

a part of the main.

John Donne

However for some children, this may not often feel the case. Children with physical disabilities may face limitations in their interactions with peers (Stevens et al, 1996).  Reduced access to participation is often not only due to differences in functional skills, but may also be due to limitations imposed by the physical and social environment (Law et al, 2007).

SpecialEffect is a charity which looks to address this issue when it comes to participation in gaming. Mark Saville, who acts as communication support for the team, was kind enough to offer his time for an interview, so I could find out more about the charity’s work.

Mark set out the aim of SpecialEffect: “To help people of all ages with physical disabilities enjoy videogames. To play video games on a level playing field with everyone else. So, for those with a physical disability to join in with their family and friends as effectively as possible.”

I was curious about the origin of this service. Mark told me about SpecialEffect’s founder and CEO, Dr Mick Donegan (an Associate Senior Research Fellow at SMARTlab, University College, Dublin, and Adjunct Professor in the Department of Assistive Design at OCAD University, Ontario), who ten years ago was working for another charity in which he was helping severely disabled children with their communication.  “The parents would come and say their children can communicate at school, but what happens when they leave?  What quality of life do they have on the weekends on evenings? This was a time when video games were on the rise. Games provided a perfect platform for people with disabilities to join in.”

Mark returned to the concept of levelling the playing field. “I think we are looking at children who don’t have the ability to run around and play like other children do. And, you know, the online version of football—FIFA, for example—comes along and they can’t play that either. They are missing out twice with their friends. The aim of the charity is to at least pull back one of those and make it possible. And by doing that, the impact is incredible. The inclusion, the raising of quality of life, is just astonishing.” 

The way SpecialEffect ‘pulls back’ is by modifying the hardware required to play computers games, in order to increase their accessibility. I was fortunate enough to trial some of their technology at Rezzed, a gaming convention in London, and was able to see the different modifications to gaming controllers which help people with disabilities engage with games.  However, the question remained whether it would allow somebody with a physical disability to play on the aforementioned ‘level playing field’.

Controllers adapted for physical disabilities

Images courtesy of SpecialEffect

Mark acknowledged that there are a lot of variables influencing whether the charity is able to help somebody. “For example, a parent or a child might come to us, and the young person is saying ‘Look, I have muscular dystrophy and I have weakness in my fingers but I really want to play Call of Duty.’ And so we say ‘Okay, we will go along and look at your specific abilities even down to the millimetre of movement you have and we will see whether there is some way, be it through joysticks, switches or eye gaze, and we will try and find some way for you to play Call of Duty.’ So that is the primary aim. And that is what I mean by levelling the playing field. We will do our utmost to make that happen.”

Mark recognises that sometimes it is a case of managing expectations. “Especially sometimes we find we are working with people who may have a condition which may be advancing. We will try to keep them playing as long as we can but we may have to progress to other games as time goes on.”

He also highlighted the difficulties in the practicalities in creating bespoke controllers for video games. “Making a general controller for accessibility for all games isn’t possible, even within a particular disability. If you look at cerebral palsy for example, every single person has different difficulties: their muscle spasm might mean they spasm inwards or outwards. There are various levels. It is therefore impossible to create a generic controller and say, ‘there you go.’”

This means that each controller made via SpecialEffect is customised for the child requesting it. This is, as Mark puts it, “the one-to-one approach.” This in turn requires a multidisciplinary team being involved, such as technologists and occupational therapists going out to visit people. “They are amazing to watch,” Mark said, “to see them working with people to produce something custom. It could be something as simple as an adapted one-handed joystick for some people who may have a problem with one hand. If it is somebody with a spinal injury, we might be thinking of a chin joystick combined with a voice control in combination with a couple of head switches on the head rest. There is a huge range of technology which includes pulse switches and eye blink switches. So we are kind of mixing and matching and creating. Sometimes we have to pull a controller apart and put holes into it and modify it in a way which makes it easier for somebody. It really is horses for courses.”

Mark described the benefit the work has had not only for the children involved, but also for the carers as well. “The impact we are finding is not just obviously fun: we are finding that especially with people with severe disabilities, if we enable them to gain three or four hours in a stretch, we are giving a lot of respite time to their carers. We are also giving those people a chance to be anonymous online and interact at the same level with the people they are playing. They may well be beating people online and those people have no idea this person has got a disability. It is a big thing.” This impact is seen through the positive feedback the charity receives. “I was talking to a parent the other day, a parent we had helped, who said, ‘Thank you, as a father, for making me feel so much better that my daughter is enjoying herself.’ And it had never struck me, before.”

Images courtesy of SpecialEffect

These accessibility modifications can also have a role in physical rehabilitation. “We may find an occupational therapist is referring someone who needs some kind of hand exercises, and for us, operating a joystick to play a game is a good repetitive hand exercise for a young child. It is a win-win. We are finding new positive impacts every day.  But mainly it is still about inclusion.”

Discussion turned to the future of SpecialEffect. “First and foremost, we want to still be doing what we are doing now because the nature of disability is never going to change. There is always going to be a huge range of disabilities displaying in different ways and we will always need to produce custom controls. But what we are also doing is working with game developers as well, to look at ways in which they want to make their games more accessible to people. 10 years, who knows? But I can assure you we will still be helping people.”

The referral pathway for SpecialEffect is completely open. Anybody with a physical disability or their parents/carers can contact the team directly (a contact form is available). “We don’t charge,” said Mark, “because we are dealing with young people and families who are facing enough pressures financially, or otherwise. The last thing we want to do is say ‘Would you like to play games? I’m sorry that is going to cost you a few hundred pounds.’”

To me, the charity seems a worthwhile cause, increasing social inclusion within an often overlooked group in society.  In most fields of psychiatry, in particular in liaison and CAMHS, we often see individuals with physical disabilities which may limit their ability to engage in what is viewed as “normal” activity among their peers. This increases their sense of isolation and distress as they feel more disconnected from those around them. This loneliness is associated with increase rates of depression and suicidal feelings (Schinka et al, 2012), while strong social networks play important protective roles against depression (Santini et al, 2015). With The Pew Internet Study (Lenhart et al, 2008) previously recognising that video games are becoming an almost universal pastime in society and that they are part of normal social engagement, reducing the barriers for people with disabilities to engage may be beneficial not only for their social interaction, but their mental health as well.


Authored by Sin Fai Lam

SpecialEffect is a registered UK-based charity. Coverage of this charity on this blog does not constitute its endorsement or recommendation by the College.



Law M, Petrenchik T, King G, et al (2007) Perceived environmental barriers to recreational, community, and school participation for children and youth with physical disabilities. Archives of Physical Medicine and Rehabilitation, 88: 1636–1642. [abstract]

Lenhart A, Kahne J, Middaugh E, et al. (2008) Teens, Video Games and Civics. Pew Internet & American Life Project. [website]

Santini Z, Koyanagi A, Tyrovolas S, et al (2015) The association between social relationships and depression: a systematic review. Journal of Affective Disorders, 175: 53–65. [abstract]

Schinka K, Van Dulmen M, Bossarte R, et al (2012) Association between loneliness and suicidality during middle childhood and adolescence: longitudinal effects and the role of demographic characteristics. The Journal of Psychology, 146: 105–118. [abstract]

Stevens S, Steele C, Jutai J, et al (1996) Adolescents with physical disabilities: some psychosocial aspects of health. Journal of Adolescent Health, 19: 157–164. [abstract]

22/03/2017 10:47:21

Through the gate and back again: how Dr Augustine Yip forged a career in gaming before returning to medicine

Within the medical community, there often are those of us who dream of venturing into other fields of interest, but due to a multitude of reasons, we are unable to take the first step. We were pleased to speak to one of the founders of the game development studio BioWare, Dr Augustine Yip, who did take that step and as a qualified doctor branched out into game development before returning to medicine full time. Dr Yip, who is currently working as a family physician in Calgary, Canada, kindly gave us a candid insight into what his life was like as a game developer, his personal views of computer gaming in general, and his transition back into medicine.

Baldur's Gate

BioWare is a video game developer that was founded in 1994 by Ray Muzyka, Greg Zeschuk, and Augustine Yip, three doctors who had recently graduated together from the University of Alberta’s medical school. The three had met in while studying Medicine and had collaborated on software for use within the medical field. After forming BioWare, they made their big break with the game Baldur’s Gate, released in 1998. From there, BioWare moved from strength to strength, developing critically acclaimed games such as Star Wars: Knights of the Old Republic, Dragon Age and Mass Effect. Dr Yip however, had made the decision to leave BioWare in 1998.

The impact of BioWare on the video gaming world was not only through its Infinity Game Engine, which was used for other computer role-playing games (CRPGS), but also through its impact upon the narrative and structure of future CRPGs. Concepts that are taken for granted in CRPGs today, such as character relationships and engaging storylines, were greatly developed and refined within Baldur’s Gate.

Regarding Baldur’s Gate, Dr Yip said “We were really, really proud with the storytelling and the idea that you can actually adventure. Other games tried to do it, but this was our attempt to have Dungeons and Dragons (D&D) role-playing on the computer.” D&D is traditionally a tabletop role-playing game, though the system and its fantasy worlds have also appeared in novels and video games. “A non-linear storyline that allowed you to explore everything else: it was a real point of pride.”

The path in game development was not smooth, however, with occasional discrepancies between the game publisher’s expectations and BioWare’s vision. “I helped create the graphical user interface, and that is a special point of pride for me. The producer--the publisher--they were called Interplay. They wanted a ‘Warcraft 2’-like interface and we had to explain, sort of vehemently, that this is not that type of game. This is a roleplaying game and it is Dungeons and Dragons.”

It is often asked how a fledgling developer obtained the rights to develop a D&D game. “Well here is the actual story,” Dr Yip explained. “For Baldur’s Gate, we made a demo of the game and we called it ‘Battleground: Infinity’ and it was supposed to be different mythologies versus each other, such as Norse mythology versus Roman mythology versus Aztec mythology versus Chinese mythology; that kind of thing. That was the demo that we brought to Interplay. And Interplay had this Forgotten Realms license which was sitting dormant and was about to be lost.” Forgotten Realms is a popular D&D setting, which has been licensed for further use in media such as novels and video games.

“(Interplay) said ‘Yeah, we like the engine but we don’t want the mythologies; we want to make the Forgotten Realms games.’ We were such geeks, having played the old D&D games with the dice and everything, and of course we just jumped all over it. So they carved out a small point in time in Forgotten Realms for us.”

How did his life as a game developer impact on his decision to return to medicine? “The journey was good. It was. But business and software development is all consuming, even more than medical school.

“To be blunt, we just, we were just exhausted. Game development was 18-hour days, no exercise, poor nutrition, literally pizzas and coke for breakfast lunch and supper. You are basically locked in windowless rooms with 50 other geeks playing games and talking about games all the time. I am an avid but uncoordinated sportsman; I play tennis, ski, badminton and golf and everything else. I just knew that I couldn’t keep doing this.”

Another influence on Dr Yip’s decision to leave BioWare was when his wife, fellow family physician Monica, and he were expecting their first child. “Though the games were doing well, we thought ‘You know what, I’d rather live a comfortable life than one filled with nothing but computer screens, geeks and rooms.’”

Dr Yip feels the role of video games has changed significantly over the years. “Well, I mean they are so huge now, they are such a gigantic industry. I feel that--having had three kids and putting them through soccer, skiing, golf and everything else--I don’t have anything against video games, but there is a whole world of real games, sports, skills and musical instruments. You know that these things matter as well. Being an excellent player for soccer games, or, whatever, any big shooter games; I am not sure that those skills would necessarily be transferable to anything else. But being able to play an instrument or reading physical literature could be more important to a person in a long run. I have no issue with gaming in general. It is just the amount of it.”

We moved our discussion onto the existence of gaming addiction and its introduction in the DSM V. “Easily could be, easily could be,” Dr Yip said. “I mean, gambling addiction… you can argue gambling in small amounts is okay, but gambling in large amounts can affect family and lifestyles. So, easily, gaming could be in the DSM classification. You can have Facebook DSM classified, and Youtube DSM classified, and everything. But gaming, for sure.”

On returning back to medicine after his time in BioWare, Dr Yip reflected on his career and whether he enjoyed the decision he made. “Oh, very much so. I have been at it for twenty years now. I have seen babies grow into adults. I have seen a generation of grandparents pass on. It has been an honour and privilege. I mean, in 22 years you can imagine the changes in therapy. My wife actually has actually branched off into psychotherapy and I have developed an appreciation of psychotherapy and its power. I have no regrets. It is funny, I have done a few of these interviews probably every two, three, four years and a lot of the interviews centre around ‘Do you regret leaving the gaming sector,’ and I say ‘No, I don’t even think about it at all.’ It is not that I am avoiding it; it just doesn’t even cross my mind.

“The computer world is so random, so much hard work so poorly paid, and basically only the top producers and developers make the big money. I mean, it was a blast, but honestly, it was for the person young, unmarried, no obligation, total freedom to work insane hours and with a high metabolism for carbs.”

Drawing the interview to a close with Dr Augustine, who was returning to pick up his children from hockey, I thanked him for helping us on this article about doctors and gaming, and he left with “Doctors formerly in gaming… It was a long time ago.”

Following the interview, I thought upon the changes within the video games especially with regards to its reflection of the psyche. Talking to a trailblazer who developed a video game where attempts were made to move away from one dimensional place holder characters, to thinking about games today that are more confident and able to reflect the emotions which come with living; there is now a recognition within the gaming community that games which emphasise the complexity in human interaction within an engaging narrative is just as important as nuts-and-bolts game play.

However, on a more personal level, Dr Yip’s story allowed me to reflect on how this person had explored his various passions and had come to a decision on the one he most wished to follow. Perhaps there should be more flexibility for us in exploring alternative career pathways, as opposed to the streamlined production factory that medicine can sometimes feel like. That way, we may have a better sense of contentment in the choices we make, instead of feeling of “what may have been”.


Authored by Sin Fai Lam

06/02/2017 11:03:04

Stéphane Cantin on why he took us on an ‘Autistic Journey’

Max, an Autistic Journey (MAJ) is a roleplaying game for Windows, which has you take on the role of Max, a ten-year-old boy with a diagnosis of Autism Spectrum Disorder (ASD). 

It allows you to experience one day in Max’s life, showing a flavour of the challenges he faces both at home and school. Battles within the game are fantastical in nature and stem from Max’s imagination, and the monsters he fights represent the stresses Max is experiencing. MAJ is notable in that it was developed by the real life Max’s father, Stéphane Cantin. Having played through and very much enjoyed MAJ, I was keen to contact Stéphane and learn more.

Donald: MAJ is a very personal work. What made you decide to create this?

Stéphane: I was playing a wonderful game called “To The Moon” from Freebird Games and Max came to me and watched me play. Then, out of the blue, he said: “Papa, I’d like to make a video game like this someday…” And the light turned on in my head! I started asking him about what he would do and it evolved into Max, an Autistic Journey. 
To the Moon

To the Moon is another RPG featuring a character thought to have ASD



Donald: What did you hope people would get out of playing MAJ?

Stéphane: I wanted to use the video game format to illustrate some of the challenges that Max has to go through. If that helps some people better understand what a ten year old boy with an Autism Spectrum Disorder could go through in a typical day, and in a fun way as well, then that’s a goal I can definitely aim for. I don’t think a game about ASD had ever been made before, so I thought that could be a great personal challenge to take on. I never wanted to explain autism; that’s not the point. It’s such a vast and complex spectrum, with so many facets… That being said, some people might recognise some of the situations that Max goes through in the game and get a better understanding. Judging is easy when you don’t understand the reason behind a behaviour… 

Donald: I love the turns of phrase used by Max in the game, such as "In fact..." How much of the real Max has gone into this game?

Stéphane: Thank you! A lot of Max’s quirky expressions went into the game. Our family is French Canadian and our first language is French. So I translated things like “En fait…” into “In fact…” The conversation between Adam and Max about the Mario princesses actually happened! I was listening to them like a fly on the wall and absolutely loved it!  

Donald:  MAJ uses the art motif of the puzzle piece, which I understand originates from the original National Autism Society (NAS) logo and was felt to represent autism as a 'puzzling' condition. Some have expressed a desire to move away from this image and the ideas it represents. What are your thoughts on this?

Stéphane: That’s a really good question! I had no idea when I started the game that the puzzle piece was somewhat controversial to some people. In Canada, it’s an accepted and recognised symbol for ASD that we see pretty much everywhere. I fully understand and respect that some people have a problem with “the missing piece” interpretation and that it suggests that people with an ASD are “incomplete” in some way or another. I personally see it more as a positive and constructive symbol, something challenging, yes, but also incredibly rewarding! All of the puzzle pieces represent every day victories to me.

Donald:  Computer games are unique in that they are an active medium. How do you feel MAJ benefited from being a computer game rather than any other medium?

Stéphane: I wholeheartedly agree with your statement! I made this game so that, to some extent, the player would get to experience the everyday challenges that Max has to face, sometimes. Reading about it or watching a video will give you some information, but actually playing it, fighting with your rising anger or anxiety, makes it much more tangible to me.

Donald:  Were you worried how people might react to it? What has the response been like?

Stéphane: Worried? Yes, definitely… Sadly, Autism is often used in a very derogatory manner and I was ready to face some “trolling”. My great publisher John Kaiser III at GPAC Games and I did get a lot of insulting comments and we dealt with them accordingly. However, what was really surprising to me was how much and how fast the fan community took care of a lot of the trolls and made sure that the whole experience remained as positive as it could be! That’s what I focused on. We received so many positive comments, personal stories of parents of children with an ASD who found some comfort in playing Max, or even adults with an ASD who shared their experience with us. I shielded Max from the negativity but I also showed him the amazing support and love that we received!

Donald:  What did you learn from the process of creating this game?

Stéphane: Making games is hard! Seriously, aside from learning about the technical stuff, I mostly learned that there are amazing people in this world! It might sound a bit corny, but the support that I received really made it all worthwhile! It took Max and me about 15 months to get to our final product. It has truly been a labour of love over many nights and weekends. It brought me so much closer to my kids and they blew me away time and again with their imagination and involvement with this project! There were many more highs than lows!

Donald:  Early on in MAJ, there is a mini-game involving vaccinations, following which the game points out the importance of getting immunised. Given the controversial media coverage from 1998 onwards that the MMR vaccine might be linked with autism (exhaustive research has since provided very strong evidence that there is no such link), is this not somewhat provocative?

Stéphane: Yes, absolutely! It’s my 'tongue-in-cheek' jab at anti-vaxxers. I believe in science… It’s time to get rid of all these falsities and the agents that spread them.

Donald:  What does Max make of starring in his own game? I note you made sure to include his siblings!

Stéphane: That’s a great question! I made this game with Max, as well as Jean-Michel, Elisabeth and Charles, to simply have a whole lot of fun discovering what a day in a life can be like sometimes for this ten-year-old boy who has an Autism Spectrum Disorder. I could very easily say that Max loved it and voilà, that’d be that. But it goes deeper as Max uses the game as a tool in his everyday interactions! That blew me away the first few times I noticed it. Let’s say we just sat down and discussed a scene together (I wanted to get his insight constantly throughout the process, of course). Then, I would create the scene and show it to him. He would play the game, comment on it and then, a week later, he would come back from school and say: “Today, I did like the Max in the game does! I closed my eyes and I took 3 deep breaths. Phew! Then I was Ok. No need to get angry…” and he sings the “Victory” sound from the game. I had to pick up my jaw off the floor…

Max must tackle everyday challenges, such as overwhelming noise

Max must tackle everyday challenges, such as overwhelming noise 



Donald: What do you think is the next big thing in computer gaming?

Stéphane: I’m not an expert at all, but just from my own experience, I see a lot of gamers looking for nostalgia and finding it in retro-style games. With the availability of software like RPG Maker, Game Maker Studio and Unity, to name a few, it’s become much easier for a lot of indie developers to create great quality games! The retro-style seems to be very popular, especially with more seasoned gamers like myself.

Donald:  What are your plans for the future now?

Stéphane: Ideally, I would love to make downloadable content for MAJ, as well as a whole new game. For now, I’m just so grateful for all the love and support that the game has received! Thank you so very much to everyone and please, let’s raise awareness about the challenges of Autism Spectrum Disorders. 

Donald: Thank you very much for taking the time to talk to me Stéphane, I really look forward to hearing about your next project.

Find out more about Max, an Autistic Journey

Authored By Donald Servant

06/01/2017 11:05:42

Using biofeedback to encourage emotional regulation with Champions of the Shenga

When the MindTech Healthcare Technology Co-operative tweeted about Champions of the Shenga, we were intrigued. It’s an 'emotionally responsive game' which rewards players for regulating their emotions. In this game, it pays to keep your cool while playing. Thus the developers hope it will help train players in mindfulness techniques.

Mindfulness is a meditative activity that originates in Buddhist practice. It helps a person notice what they are sensing and thinking, and how they are reacting to it, in a non-judgemental way. This allows the person to be more aware of such feelings, and enables them to react differently, in more constructive ways. There is growing research into mindfulness-based therapies, and current evidence supports the use of mindfulness-based cognitive therapy for prevention of relapse in people who are currently well but have experienced three or more previous episodes of depression.

Champions of the Shenga will use a Bluetooth sensor to detect the players’ heart rate and claims to use heart rate variability (HRV) as a measure of the players’ stress and anxiety. The game itself is a card duelling game with a fantasy theme, and can be played against players across the world. A player is more powerful within the game if they are able to utilise diaphragmatic breathing exercises in order to raise their HRV, which the game understands as a measure of reduced stress. The game asks players to 'gather magic power' through controlled, focused breathing.

Simon Fox, the Design Director of BfB Labs gave us more information about their upcoming game.


Can you tell us about your game Champions of the Shengha?

Champions of the Shengha is a card duelling game that senses your emotions. Players step into the role of would-be Champion engaged in magical duels - casting spells, summoning creatures and deploying their best strategy in order to achieve victory. In order to conjure magic players do what they imagine a real spellcaster might - focus their mind and body as measured using our wearable sensor. Our players must adopt and learn key emotional regulation strategies evaluated using heart rate variance data streamed live while they play.


Champions of the Shenga






The game comes with a sensor for biofeedback







What was the motivation behind the game?

Our game teaches players the kind of skills which sit at the core of philosophies like mindfulness, or even therapies such as Cognitive Behavioural Therapy.

The idea that the physiological response of our bodies to external stressors can be observed consciously in the crucible of our cognition. That we can forge a little space between our immediate autonomic response to a situation and our conscious behaviours. This is interesting stuff! As a designer I feel lucky to be engaging with these kinds of problems.


How did you decide upon using the emotions fear, fury and joy as the three tribes within the game?

We wanted the player’s tribal allegiances to underscore the games’ pedagogic content. In the future we will deploy expansion packs which contain series’ of missions including ‘in-fiction’ pedagogic content designed to teach players the value of embracing and experiencing challenging emotions.


Do you see there being an expansion pack for other emotions?

We hope so!


What’s unique about using a game to understand mindfulness and emotional regulation?

Building consciously around impact is a new sort of challenge for a games designer. You might begin designing a game around a cool story or character your players would want to engage with, or an interesting set of rules. We begin with a measurable change we want to make to a user’s life.

To do this you need both designers and researchers on your team, and you need to let both do their job. Letting your games designers be playful with the subject area and technology, while ensuring you are designing around measurable impact is a big challenge.


Champions of the Shenga cards


The card-duelling game will reward players for using mindfulness-based techniques




Why do you think games have such potential for exploring mental health?

Games drive intense engagement when they work. They are inherently pedagogic systems which immerse their users in a new world with new rules - rules which must urgently be learned to succeed. The motivations for play are very interesting - it’s an active learning state in which players adopt a lusory attitude in which we will accept and adapt to new norms. Our ability to explore the system of a game, to master those rules or to share that experience with others may one of several core motivators. That play is motivated intrinsically by its own value makes it a great candidate for teaching skills or creating interventions to which participants adhere.


Where do you see gaming and mental health going as a field in the next 5 – 10 years?

Games design and good design in general seeks to engage a very deep understanding of its user and make that understanding fundamental to the creation of an artefact. Most psychological health interventions still come from a rather didactic place. I foresee a future where more effective interventions are designed - interventions which adapt themselves to their user, changing their mode as the user progresses. I foresee interventions which engage deeply with their users rather than being imposed upon them. I foresee a scalability driven by ubiquitous technology that allows many more people access to effective services than currently enjoy this privilege.


We’re in a golden age of board games at the moment, why do you think this is?

Board games are a fantastic way to get involved in games design. The cost of entry is low and it’s easy to try new things! You can totally rebuild a board game in an afternoon. Compare that to video games where the cost of an iteration can be a team of people working for 2 weeks or more.


What’s the last board game you played and really enjoyed? 

I enjoyed Pandemic a great deal. Suburbia is also very nicely designed. I personally like games which are about communicating so things like Resistance and Werewolf are great fun for me. I’m also a big geek so card games like Netrunner tickle my strategy bone.


What’s the last computer game you really enjoyed?

I’ve splashed out on a VR headset for my home (cf. big geek) and the last thing I played on it was a surreal comedy adventure called Accounting...


Where can we find out more about Champions of the Shengha?

Check out our website!


Authored by Stephen Kaar



05/12/2016 16:38:43

EGX 2016 - A meeting of minds

This year’s EGX 2016 was held at the NEC in Birmingham, and featured the usual stellar line-up of blockbuster playable previews.  Gamers queued to sample Final Fantasy XV, Gears of War 4, Dishonored 2 and other heavyweights.  However at this annual gaming convention, as in life, I found the most interesting bits to be lurking at the margins, and the buzz around the indie games section showed I was not alone.

EXG 2016

EGX is a videogames convention that hosts 75,000 gamers over four days



The National Film and Television School (NFTS) had brought along a variety of talented new game developers with a range of backgrounds – from fine art to philosophy to science – and this was reflected in the eclectic mix of games on show.  When I asked an NFTS course coordinator about the intersection between gaming and mental health, I was steered over to The Circle,  an ‘interactive virtual reality experience’ from Manos Agianniotakis. 

The gameplay is about a woman dealing with post-traumatic stress disorder (PTSD), who has cut herself off from the world following a traumatic event. You explore her back-story whilst solving a mystery inspired by the real-life Toynbee Tiles  

The first-person aspects of the game feel appropriately confined, limited to the desk in front of you. Upon the desk are a computer, phone and letters, which comprise the whole of this woman’s communication with the outside world.  The use of a virtual reality (VR) format only seems to emphasise the claustrophobia of the situation.  VR was a pervasive feature of the 2016 convention as a whole, and The Circle shows that VR is not only good for first person shooters, but could also have a role in producing more complex immersive experiences with a psychological impact.


The Circle

The Circle is a VR mystery game that examines the fears of a woman who has developed PTSD


This is not Agianniotakis’s first foray into exploring mental health themes.  His previous title, An Interview is a very short interactive story based on Tim Grayburn’s personal experience of depression as depicted in the play ‘Fake it ‘till you make it’.  This project was borne out of Agianniotakis’s personal interest, rooted in an experience of depression within his own family.  It successfully meets the developer’s aim of opening a conversation about the stigma around male depression, and has been featured on


'An Interview'

An Interview aims to capture the complexity of the struggle with depression



Other gems from the indie games section included A Normal Lost Phone by Accidental Queens, in which you uncover the story of the phone’s owner by interrogating the contents of the phone (with echoes of Her Story by Sam Barlow. 

John Lau’s Uncanny Valerie also raised interesting ideas about personality and relationships, as a robotics engineer decides to program her ex partner’s consciousness into a robot.  How do we cope with loss?  What would life be like if we could simply get rid of a person’s flaws?  The title also wins the prize for best pun, with a nod to the Uncanny Valley hypothesis.  This states that as robot replicas become almost but not fully human, they will elicit eeriness and revulsion amongst observers.  This cognitive response has been mapped by researchers to specific areas of the brain using fMRI


My final reflection is on the most important ingredient of EGX 2016 – the people who attend.  Often a solo pursuit, gaming conventions offer a unique opportunity for various parts of the gaming community to get together.  As someone interested in how gaming and mental health may interact, I could imagine such conventions as fertile grounds for mental health research and advocacy, both in terms of understanding mental health issues facing gamers and the potential mental health benefits of good gaming.  If we can harness this resource, and be as innovative in doing so as the game developers constantly breaking new ground, then the future looks exciting.



Authored by Fran Debell (Core Trainee in Psychiatry, South London and Maudsley NHS Trust)


18/11/2016 10:11:52

Living with autism in 'Max, an Autistic Journey'

As someone who has previously worked within an autism service I was interested to play Max, an Autistic Journey (MAJ), both to see its portrayal of autism spectrum disorder, and also to see what the game had to say about it. The game is described by the developer, Stéphane Cantin, as a 'true labour of love'. The game aims to 'help explain to everyone a typical day for a ten year old who has autism'. It is notable that the titular main character Max is based upon Stéphane's own son.

The first thing to say about MAJ is that it has a sense of heart, from the generally upbeat tone of events to the occasional flecks of pop-culture-referencing humour. The four-hour long game truly feels like a story written by a father about his son. The challenges Max experiences throughout an entire school day are portrayed with sympathy. Regular pictographs pop up to help explain in layman's terms the elements of autism that have been depicted in the game.

Symptoms and behaviours of autism are explained regularly throughout the game

Symptoms and behaviours of autism are explained regularly throughout the game

MAJ plays like a traditional top-down roleplaying game (RPG), reminiscent of the Super Nintendo era, and it was created using the RPG Maker engine. The game involves strolling about Max’s home and school while talking to his family and friends, in addition to battling enemies which appear to represent a mixture of creations of Max’s imagination and metaphorical representations of his anxieties. This RPG gameplay standard is interspersed with a variety of mini-games.

I feel this is a good medium to tell such a story (as opposed to passively reading a book or viewing a film on the subject), as playing through the events of Max’s day can bring home how Max’s symptoms can functionally affect his day to day life.Max battles metaphorical manifestations of his struggles, such as this fight with Anger  

Max battles metaphorical manifestations of his struggles, such as this fight with Anger

MAJ manages to cover quite a few concepts relating to autism. The behaviour portrayed in the game rang true to my personal experience working within an autism service. While the game does acknowledge the variety of ways that autism can present, this game is very much about Max’s particular situation.

Max's distress at the amount of noise in the classroom is vividly shown when his fellow pupils are depicted as monsters until Max manages to obtain a pair of noise-reducing headphones. There also seems to be evidence of stilted/stereotyped language: for example, most sentences spoken by Max begin with the words ‘In fact’. 
 As Max becomes distressed by noise, his classmates are depicted as monsters

As Max becomes distressed by noise, his classmates are depicted as monsters

The game also demonstrates Max’s need for a regular routine and how distressing it can be to have it disrupted. Early on, Max has to use a toilet other than the one he would typically use, causing Max to become anxious. An on-screen meter ‘anxiety meter’ visually provides an indication of those situations that Max finds difficult or anxiety-provoking. When this meter fills up, Max can have a severe tantrum, which is another behaviour that Max and his family have faced difficulty with. One of the coping strategies that Max uses to avoid tantrums is breathing exercises, and there is a simple mini-game used to demonstrate this.

Max is shown to have specific and in-depth interests, such as his interest in different breeds of dinosaurs, which feature throughout the game. The game also features a brief reference to repetitive behaviours when it is mentioned that Max has drawn the exact same pictures in his art class for years. MAJ includes scenes demonstrating some of the difficulties in social interaction seen with autism; for example Max states that he finds a friend ‘boring’ and then does not understand why his friend becomes upset.

MAJ gives what feels like an honest description of the typical difficulties related to autism spectrum disorder that a father has noted in his son. When I state honest, I am not claiming to have witnessed the real Max but rather that there were a number of little touches in the story had that had a ring of truth for me. The game is not too information-heavy, but it does break up the gameplay with occasional facts about autism. By and large the game portrays autism spectrum disorder in a positive and frank way.

I enjoyed playing MAJ and being given a little window into Max’s life. It is reasonable to say the game succeeds in its aim to 'help explain to everyone a typical day for a ten year old who has autism', if you give the proviso that autism spectrum disorder presents in a variety of ways and that this story is solely focused on this boy’s specific experience.

Max, an Autistic Journey is playable on Windows PC. Review key was provided by GPAC Games and Dietrich Online Services

Authored by Donald Servant



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The Gaming the Mind team are all doctors within South London and Maudsley NHS Trust

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Sin Fai Lam (Higher Trainee in General Adult Psychiatry)

First game ever played?

Double Dragon on the PC

What game made an impact on you?

Indiana Jones and the Fate of Atlantis – for making me wish to become an archaeologist… though I failed miserably in the process...

Where are you now?

On a train getting querying stares as I WhatsApp these answers.


Stephen Kaar (Higher Trainee in General Adult Psychiatry)

First game ever played?

James Pond on the Amiga

What game made an impact on you?

Doom – the first game I played in which a digital 3D world started to feel real

Where are you now?

Sat in a café in Camberwell eating falafel.


Donald Servant (Higher Trainee in Psychiatry)

First game ever played?

Super Mario Bros on the NES

What game made an impact on you?

Undertale - beautiful music and a vivid cast of characters that the game made me care about.

Where are you now?

Sitting in a café in Camberwell eating chicken shawarma with Stephen and Sachin.


Sachin Shah (Core Trainee in Psychiatry)

First game ever played?

Captain Planet and the Planeteers on the Amiga

What game made an impact on you?

Shadow of the Colossus - a game that made me question my murderous actions

Where are you now?

Help, I'm trapped in an infinity machine.

Reference on this blog series to any specific commercial product, service, manufacturer, company, or trademark does not constitute its endorsement or recommendation by the College.