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

Gaming the Mind

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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 GateBioWare 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.”

Dr Yip expressed some frustration with the process of writing for the Forgotten Realms world. “Our writers wrote everything in that game. But everything had to pass through that Salvatore guy [R. A. Salvatore is known amongst other things for his Forgotten Realms novels], and unfortunately this is the way it is like in the writing world, he got a lot of the credit for writing about the world and all the storylines and actually it was a group of often teenage boys that wrote all these little storylines and dungeons and traps and everything else in the story.”

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



08/08/2016 10:59:59

Bullying, depression and suicide: taking responsibility in 'Life is Strange'

Life Is Strange was conceived primarily as a game about teenage struggles. Though there is a fantasy element, involving main character Max’s ability to rewind time and correct past mistakes, this is meant to serve only as a backdrop to the everyday trials and tribulations for Max and her fellow students at Blackwell Academy. After witnessing a horrifying incident, Max discovers her powers, and from then on uses these powers to help herself and those around her.

You made me realise I wasn't alone

Depression and suicide is still relatively new ground for games, and few games have tackled these issues as head-on as Life is Strange


Max's world is filled with teenagers based on various Hollywood high school archetypes. The developers, Dontnod Entertainment, intended the game to unflinchingly tackle real issues teenagers would face, and so they end up covering difficult subjects such as cyber-bullying, mental illness, and suicide.

As the player, you control Max, navigating her through everyday environments such as classrooms, dormitories, and family homes. You can inspect items in these environments, like a detective of ordinary life, and speak to the characters that inhabit this world. At times the game poses you with difficult choices, which will profoundly affect the course of future events. Do you let your friend be scolded by her father for having weed in her room, or do you take the blame instead? When a school bully gets a taste of her own medicine, do you humiliate her further, or show her compassion? There are no “perfect” answers, so you are free to act however you feel is appropriate. The game does not shy away from dealing with serious issues and throws tougher dilemmas at the player later on; decisions that some players spend minutes agonising over.

Psychiatric themes lace the plot of Life is Strange, and a few characters are shown, either explicitly or implicitly, to be experiencing mental illness.

One of the game’s more challenging series of scenes focuses on the character of Kate, a student at Blackwell who is mercilessly bullied, both at school and online. Kate is a kind-hearted, strictly religious, reserved person. If you explore her room, you will see evidence of her strong faith, and her highly judgemental family. Sadly for Kate, somebody drugs her at a student party, and soon a compromising video of her is posted online. Incessant bullying and teasing ensues. She finds little support; you can view a letter from her parents, in which her mother writes: “We hope you haven’t brought shame upon you or our family.”

For Kate, this experience sadly leads her to severe depression. Evidence of this is found as you explore her room. Her mirror is covered up so she doesn’t have to look at herself. Her room is kept dark. Observing her violin shows she hasn’t played it in weeks. She has stopped tidying her room, when usually her room is immaculate. Overall, it paints an impression of the low mood, lack of energy, and loss of enjoyment which come with depression. Kate feels helpless and hopeless, saying “I’m in a nightmare and I can’t wake up… unless I put myself to sleep.”

Throughout the first act of the game, you are presented with opportunities to be supportive to Kate, be it having a friendly chat with her, helping to remove insulting graffiti about her, or by being available on the phone for her. Unfortunately it’s clear that you alone cannot cure her of her depression. Eventually, Kate, feeling alone and abandoned, ends up on the roof of a school building with the intention of ending her life.

Here the game presents you with an opportunity to talk her down to safety. If you have paid attention to her story so far, and have been a good friend to her, there is a good chance that you can convince her to stay strong in the face of bullying, and remind her that she has family members who would be devastated if she were to die.

This of course is sensitive subject matter for a game: if you don’t say the right things in this scene, and if you haven’t built a strong relationship with Kate, there’s a chance that things could go horribly wrong. The developers were mindful that this was essentially “gamifying” a suicide attempt, and had to take care not to trivialise the issue. One important step they took was removing Max’s powers during this scene, so that the player would deal with it strictly on a human level.   

The developers made sure that this was a scene that continued to matter throughout the course of the game, as it would belittle the moment if it was quickly forgotten. Max continues to dwell on the moment as the game progresses, as do other characters. If Kate survives, you will continue to converse with her over text messages, and eventually visit her in hospital, where she is shown to be recovering. This hospital scene provides a strong sense of hope and closure, indicating people with depression can find help and can get better.
Life is Strange

The developers were also aware of the impact such scenes may have on players, and produced a web resource for those affected by issues in the game

The developers have gone to great lengths in trying to tackle the subject matter sensitively, including researching about bullying, reviewing suicide prevention materials, and speaking to mental health professionals about how best to speak to people who are having thoughts of suicide. They were also aware of the impact such scenes may have on players, and produced a web resource for those affected by issues in the game.

What makes Life is Strange so impactful is that, despite the fantasy element, it essentially takes place in our own ordinary world, and stars believable characters not unlike people we already know. As you grow attached to characters like Kate (just one of a wide and fascinating cast, all with their own issues to deal with), it makes the overarching story of time manipulation all the more compelling. I’ve neglected to mention the key plot element: the story of a teenage girl who has disappeared from the community. As the game progresses, you will learn the dark secret at the heart of this small town, but much like the television series Twin Peaks was about so much more than the murder of Laura Palmer, this game is about so much more than the core mystery.

This game can be played at a leisurely pace, allowing you to become lost in its fully realised, detailed world. It is rich in character, and features a warm acoustic soundtrack, for a late-2000’s indie-film feel. It is widely regarded as one of the best games of 2015 and is a must for anyone who enjoys strongly narrative-driven interactive experiences.

Depression and suicide is still relatively new ground for games, and few games have tackled these issues as head-on as Life is Strange. Playing the game I get the feeling that developers are still finding their feet on the best way to deal with such subject matter, but I certainly admire the bravery with which they explored it, and their attempts to remain respectful.

You can find more information on the emotional cost of bullying here.

Life is Strange is available across multiple platforms including PC and Mac via Steam or Humble Bundle, as well as on Xbox and PlayStation consoles.

Authored by Sachin Shah




13/09/2016 13:22:00

Challenging harmful stereotypes: Lucy Morris on why she created Asylum Jam

Challenging harmful stereotypes: Lucy Morris on why she created Asylum Jam

Following on from my blog entry ‘The Asylum Jam Challenge’ back in May, I was excited to reach out to the founder of Asylum Jam: artist and game designer Lucy Morris.

Despite her busy schedule teaching the Bachelor of Creative Technologies programme at the prestigious Media Design School in Auckland, New Zealand, Lucy very kindly agreed to an interview so we could learn a little more about her and the Asylum Jam concept.

What is the last game you really enjoyed?

Lucy: I actually just finished playing Life is Strange from start to finish, and absolutely loved it. Not only is it a finely woven narrative experience, but it also tackles a lot of 'taboo' issues attributed to growing pains or young adult life that many games don't touch or consider (i.e. sexuality, drug use, bullying, depression). ...and of course, all that is aside from fantastic art and audio direction.

Life is Strange




Life is Strange, a critically-acclaimed adventure game, praised for its coverage of ‘taboo’ subjects.




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

L: I think it would be naive not to recognise virtual and augmented reality are the next step for games in general. We're already one of (if not the most) interactive mediums available, and having that extra layer of immersion in virtual reality is going to present a lot of great opportunities and challenges. VR and AR also spell great things for serious games and wellbeing - the latest fad of Pokémon Go's AR app and how that has impacted people's attitude towards exercise has already been discussed widely in media.

D: Are there any games you have seen that come to mind as being particularly egregious with regards to mental health?

L: I'm loathe to point fingers at any one title or studio because treating mental health with respect and mindfulness is a responsibility that falls across our entire industry, and no one game, book or movie is singularly to blame - rather it is the global normalisation of perpetuating harmful stereotypes. As for games that are particularly egregious, the worst representations are usually found in the horror genre and incorporate stereotypes that people who are mentally unwell are uncontrollably violent, antipathic, sadistic or twisted.

The Asylum in Thief




The ‘Moira Asylum’ from Thief 4. The Thief series has made much use of the abandoned medical asylum trope.



D: Asylum Jam is a fantastic idea, where does it originate from?

L: Thank you! Asylum Jam came about in 2013 after reading a very well written article by Ian Mahar, a neuroscience PhD candidate, addressing the state of mental illness representation in games and the stigma that comes with it. I wanted to find a constructive, positive way to explore games outside of these stereotypes, and a game jam - an event intrinsically designed to end up with an interactive artefact - seemed perfect. The jam isn't about censorship or the policing of content, but rather challenging ourselves creatively as developers and in turn, our industry, to explore games outside of tired and harmful stereotypes. As I'm originally from New Zealand - a country where mental health is a particular issue for our society - it seemed like a natural step to take to try and create some positive discourse not only around the industry I'm part of but an ongoing issue in my own local sphere. Working to remove stigma from mental illness is a cause I'm particularly passionate about as well, as I have experienced multiple personal losses from it, and feel that we should be creating a more welcoming, accepting climate with less misinformation.

D: From previous Jams, what games have you particularly liked?

L: Two of my favourites would have to be One After Another by Elisha Ramos for Asylum Jam 2014, and Tourist by Owlcave for Asylum Jam 2015. Two very different games, but creative interpretations of the horror genre.

One After Another




One After Another, one of the games produced for Asylum Jam 2014 by Elisha Ramos.




D: What has the response been like to Asylum Jam?

L: Over the years it has run, the response has been almost entirely positive, which is fantastic. Since 2015, we started developing a closer relationship with the YouTuber community as well, since horror games are often popular fodder for 'Let's Play' videos, and that experience was really great. We had almost 50 YouTubers partner with Asylum Jam in 2015, and we're hoping to expand that relationship come the next iteration. A lot of participants are returning year after year to take part as well, which is heartening. It only seems to be growing bigger, and I would like to think it is a positive force for change or exploration.

D: What other projects are you currently up to?

L: The majority of my time these days is spent doing the magical trinity of teaching (preparation, classes and marking) as I'm a tertiary lecturer in game design - but I do have a few of my own development projects on the side for when that fabled 'free time' arises. I also continue to do a lot of community building in my local and international games industries.






Tourist, a game produced during Asylum Jam 2015 by ‘Owlcave’.





D: Will there be an Asylum Jam 2016?

L: Definitely! Not only does the jam have a positive message, but it's also become a fun annual event for those of us who both love developing horror games and challenging ourselves. We'll be back in 2016, bigger and better than ever.

D: I much appreciate you taking the time to describe a little bit more about Asylum Jam and I sincerely hope the next one is even bigger and better, I certainly will be waiting with bated breath!

You can find out more about Lucy Morris and her broad range of activities within the game developer community at her website.

Authored by Donald Servant

29/07/2016 12:39:30

The Beginner’s Guide

Navigating intimate internal worlds in The Beginner’s Guide

If we can believe what we are told, the ‘beginner’ of The Beginner’s Guide is a friend of the game’s narrator.  The narrator in question is Davey Wredon, a real-life game designer who hit indie super-stardom after the release of his first game, The Stanley Parable. The Beginner’s Guide is Wredon’s hotly-anticipated second game, in which he plays the role of narrator as himself. Or does he?Navigating intimate internal worlds in The Beginner’s Guide’s a game rich in symbolism that becomes ever more intriguing...

This is a story-driven first-person game that finds you navigating through a series of half-finished 3D levels and environments that we’re told were created by the ‘beginner’--also known as Coda--at different points in his life. As you play chronologically through Coda’s games, his story and his relationship with Wredon, the narrator, unfolds. Essentially there are three characters: Coda, Wredon, and you.

According to Wredon (who narrates to you throughout the game), the design of each level, both in form and function, is a representation of Coda’s internal world. Each game is interpreted as if Coda treated the Source Engine, the program used to make the game, as a blank canvas to express his mental state at the time he made the game. A single lamppost alight in the dark; a simple house revealing a hidden underground labyrinth; an on-stage encounter becoming a high-pressure social situation; a staircase that is impossible to climb; it’s a game rich in symbolism that becomes ever more intriguing as we learn about Wredon’s connection with Coda.The Beginner's Guide

I, like many others, found the journey through the game profoundly moving

It’s never clear whether Coda is a real person, known by Wredon in real life, or a fictional mirror character that represents Wredon himself. This autobiographical aspect becomes more apparent as we discover the background to Coda’s life and his state of mind during the making of the levels through which you play. The game becomes an exploration of obsession, self-esteem, fear, fame, fortune, and meaning.

The game is short, so should be completed over a few hours, but it is paced perfectly. I, like many others, found the journey through the game profoundly moving, which is not to say that the experience was in itself depressing or a struggle to complete. There’s room for reflection and introspection but this isn’t forced; it feels natural in the space it creates. I believe one of Wredon’s aims was to help the player empathise with the feelings and behaviour of someone struggling with negative thinking and to offer some solutions to those in such a situation. This is achieved in a fun and playful manner that often surprises due its ingenious design and the apparent honesty of the emotive account the narrator gives of his relationship with Coda.  

The Beginner's GuideOne criticism could be that the ambiguity surrounding the true identity of Coda diminishes the connection the player feels with the game’s subject matter; however I believe the likely underlying autobiographical subtext means these feelings presented within the game are/were real. For me, this ambiguity adds to the game, however for those who enjoy a more complete, neat gaming experience it might be frustrating. 

The Beginner’s Guide is truly original in its conception and execution and I highly recommend it, especially for those looking for a gaming experience that is more thoughtful than the typical first-person shooter. It continuously plays with the notions of perspective and interactivity in storytelling, yet still manages to engage the player on a deeper emotional level that creates an experience unlike any other. It is available to play on PC and Mac via Steam or Humble Bundle. 

Authored by Stephen Kaar


30/06/2016 10:51:55

Playing psychologist in Phoenix Wright: Ace Attorney – Dual Destinies

Athena Cykes is a newcomer to the Ace Attorney series, making her debut in Phoenix Wright: Ace Attorney – Dual Destinies. The game came out all the way back in 2013, but I somehow held off playing it until recently. Athena, being a trained psychologist as well as a lawyer (highly impressive, considering she's aged only eighteen!), certainly caught my attention.

Like the other attorneys you play as, Athena has a distinct ability. It starts in court: your task is to defend a woman accused of setting off a bomb. Unfortunately, this defendant is having difficulty recalling all the facts during her testimony.

 “She's so scared...” Athena notes. “I think she could collapse at any second!”

Phoenix Wright, the titular ‘ace’ attorney, explains that Athena is able to use her finely tuned sense of hearing to “sense how a person is really feeling from the tone of their voice.”

This instantly struck a chord with me because it's what we do all the time within healthcare. True, we lack Athena's finely tuned hearing, but we do have extensive experience listening to people and trying to understand them. It's a very human skill and we all use it in day-to-day life: just by hearing someone talk, you might be able to tell how they feel, without them ever explicitly telling you. When I assess someone's mental state, I make note of several things about their speech, but really we all do the same thing without thinking about it: how fast are they talking; how loud are they speaking; what is the flow of their speech like? It helps a lot in understanding a person's mind.

The game describes that Athena uses analytical psychology techniques, but simply put, what she does is pick up what emotions the witness is expressing (sadness, happiness, anger, or surprise) and compares it to what the witness is saying. If Athena picks up a discrepancy, she can then tease at it to help the witness reveal what they are really thinking. The initial inconsistency you find is when the defendant expresses happiness while describing a memory of rubble falling over her.

In Psychiatry, we also look for inconsistencies between a person's apparent emotion and what they are saying. We call it “incongruent affect”. Here, “affect” is used to mean how a person feels towards something at a particular time. To have an “incongruent” affect means having an affect that is inappropriate for your thoughts. A simple (perhaps overly simple) example would be someone laughing while describing a personal tragedy.

In the Ace Attorney world, an incongruent affect always has a logical explanation. It turns out our defendant was happy when she recalled almost being buried in rubble because she was also remembering being rescued from that rubble by a man (which she previously neglected to mention). But thanks to Athena being able to pick up the discrepancy between the defendant's emotions and the defendant’s testimony, we edge slightly closer to the truth.

When we see people with mood disorders, for example depression, we might find their affect doesn't match the context they are in. But people with depression aren't typically described as having incongruent affect. Remember, incongruent affect is when your affect is inappropriate for the thoughts you are having. What is often the case in people with depression is that their thoughts are just as negative as their affect is (imagine experiencing constant thoughts of worthlessness, hopelessness, and excessive guilt), and so it's entirely appropriate that someone with such thoughts would also have a low affect.

Where we do tend to see incongruent affect is in people with psychosis, who may, for example, laugh or smile without apparent cause. This may be because they are responding to some internal thought process such as hallucinations or bizarre thoughts.

The game is scattered with moments where you, as Athena, are able to check for inconsistencies in a witness's emotions. I feel it is an excellent way of incorporating psychological technique at least on a basic level. I like the concept of working out how a person's apparent emotion betrays their inner thoughts.

Athena shows off her abilities more in the second case. There has been a murder, and your first witness is describing how she came upon the scene... or at least, she's trying to. But she seems to be in a highly agitated state, cowering in fear one moment, and yelling curses the next. Eventually she testifies, “All I know is the room was swimming in demons!” The prosecutor immediately dismisses this testimony as ludicrous and delusional.

But Athena has another explanation. She offers that the witness's memory is simply clouded by fear. “She's obviously not herself,” Athena notes. “The trauma of discovering that crime scene has her dazed and confused.”

Upon analysing the witness's emotions, Athena further concludes that “She's under an uncontrollable amount of distress, which is masking her other emotions. It seems the sheer terror of what she experienced is making her a confused mess.”

What is the game describing, here? In the world of Ace Attorney, the legal system moves very quickly, and the poor witness stumbled upon the crime scene only the day before! It seems the most likely explanation, as far as we can diagnose a videogame character, is that the witness is suffering from an acute stress reaction. It's hard to tell if the writers intended for her to fit the overall picture of this known condition; I suspect they simply intended to show the broad psychological impact of experiencing a severe mental stress (as comical as their depiction is).

And what about the demons the witness believes she saw? Wright, in discussion with Athena, wonders if “all those demons she thinks she saw are a product of rampant emotions?” Athena agrees, responding, “Her fear has instilled in her hallucinations and false memories.”

Here, Athena falters in her elaboration: “She's seeing normal everyday objects as monsters in her mind. It's a form of schizophrenic hallucination brought on by emotional trauma.” While I appreciate the game's attempt at including psychiatric explanations, I don't think what is being described here truly counts as hallucinations, and certainly this is not “schizophrenic”.

In the game, you proceed to point out to the witness the objects in the crime scene that correspond to the demons she thought she saw. As you present this evidence, the witness comes to understand she never truly saw demons.

So why wasn't the witness really experiencing hallucinations? Well, hallucinations are basically things you perceive when there is nothing there to cause that perception. When the witness saw demons, it was based on existing objects combined with her own mental images. These are called illusions, and we experience them all the time. There's different kinds of illusions, and the one the witness seems to have experienced is an affect illusion. This is when your affect makes you perceive something incorrectly. A common example is someone being scared while outside in the dark, and seeing a frightening attacker instead of what is actually a tree. Meanwhile, the witness in the game may have experienced an admittedly cartoonish version of an affect illusion, but it still fits the description.

Thus, admittedly, the game stumbles through some psychological and psychiatric concepts, but it is commendable that such things are included at all. I can’t expect the game’s depiction of psychiatry to be accurate, especially bearing in mind that the Ace Attorney games hardly take place in a realistic universe. It’s also commendable that this is a rare example in videogames of a lead character being a psychologist and using a psychological approach to help others.

I recommend checking out Phoenix Wright: Ace Attorney – Dual Destinies. If you like the sound of Athena and what she does, you'll be pleased to know that despite the name of the game, it really is all about her. The game suffers as usual from some frustrating moments of blurry logic, but the writing is as sharp and endearing as ever.

Authored by Sachin Shah



26/05/2016 12:57:40

The Asylum Jam challenge

In life, we wear many hats.

As a gamer, I enjoy most genres. I look back fondly on horror classics such as Silent Hill II and the early Resident Evil series. Falling deeper and deeper (both metaphorically and quite literally) into the foggy world of Silent Hill II is one of the most vivid memories of my youth.

As a doctor working in mental health, I feel I have an important role in challenging the stigma of mental illness where I see it.

Sadly, these interests can at times clash, as some games have a track record of treating mental illness with the subtlety of a brick hurled through a window. Horror games can be the worst offenders, using the mentally unwell as a cheap trick to shock or frighten the player. Consider the murderous artist 'Sander Cohen' from Bioshock, who is described as 'a real lunatic', or the rather on-the-nose 'Crazy Dave' from Plants versus Zombies, who sports a bushy beard, an un-tucked white shirt and a dented saucepan on his head, and seems to utter only gibberish, his slogan being: "BECAUSE I'M CRRRRRAAAAAAAZY!"

The use of the 'asylum' as a horror environment is a well-worn trope, inspiring a category on Wikipedia entitled 'Video-games set in psychiatric hospitals' which is no doubt incomplete, having missed the Thief series, which has visited the concept of a haunted old asylum more than once!

This is why I was excited to learn about the game jam known as Asylum Jam.

A game jam is a gathering of game makers, who compete to make functioning games over a short period of time. Because of the speed at which the competitors must work, game jams often produce avant-garde games (Superhot and Surgeon Simulator 2013 both originated in game jams).

Asylum Jam challenges game developers to create horror games free from mental health stereotypes. Its sole stipulation for developers is to "not use asylums, psychiatric institutes, medical professionals or violent/antipathic/’insane’ patients as settings or triggers."  Developers are given 48 hours to craft their game before the games are played and ranked on criteria such as 'innovation', 'atmosphere' and 'scare factor'.

And with that, hundreds of participants have created oodles of games managing to show how easy it is to scare, without needing to misinform.

Asylum Jam has been running yearly since 2013 and more information can be found (including the games to download) on the Asylum Jam website or on their tumblr
What thoughts do you have about how horror gaming approaches mental illness? Do you know any horror games which cover mental illness well? Please leave us a comment.
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 cafe 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 cafe 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.