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

Gaming the Mind

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29/08/2018 11:28:57

When the fun stops: Dr. Henrietta Bowden-Jones and Professor Andrew Przybylski on ICD-11’s new gaming disorder

Concerns around video game addiction are nothing new, tracing as far back as Space Invaders in the early 80s (Elgi, 1984). Decades later, gaming disorder has been recognised within the pages of The World Health Organisation (WHO)’s updated diagnostic manual: the International Classification of Diseases 11th Revision (ICD-11). Placed within the “disorders due to addictive behaviours” section along with gambling disorder, the condition describes distress or interference with personal functions as a result of persistent or recurrent gaming behaviour.


It’s been a long time coming

Gaming disorder’s inclusion within the ICD-11 was not exactly a given. The USA’s primary diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), had included “internet gaming disorder” (IGD) only as a prospective disorder for further study, an inclusion which was controversial at the time (Salloum, 2013), and came amidst concerns that the DSM-5 would pave the way to “make a mental disorder of everything we like to do a lot.” (Gross, 2013). Meanwhile, some members of the WHO’s working group for impulse control disorders suggested there was insufficient evidence to justify gaming disorder’s classification within ICD-11 (Grant, 2014). However, gaming disorder did find a home among the WHO’s addictions experts, who had first looked broadly at problem behaviours involving electronic devices and the internet, acknowledging that further research was needed to understand the phenomenology and prevalence of these problems (WHO, 2015), before honing in on gaming as the object of greatest concern (Saunders, 2017).

By the end of 2016, a group of scholars (Aarseth, 2017) raised concerns about what they felt was the premature inclusion of gaming disorder within ICD-11, noting poor existing evidence, low quality research, lack of consensus on symptoms, and that the description of the disorder seemed all-too-similar to those of gambling and substance use disorders.


The controversy

We spoke to Professor Andrew K. Przybylski, experimental psychologist and Director of Research at the Oxford Internet Institute, University of Oxford. His team is actively involved with researching video games and other internet media and how we engage with them. He has been critical of the gaming disorder classification, and was a contributor to the Aarseth et al open letter. “Games have really gone from a niche thing to something that the great majority of young people and adults play,” he said. “I think that inertia alone is enough to explain gaming disorder being included in ICD-11.”

Escalating concerns about problem gaming can feel out-of-keeping with how big the problem actually is. There are over a billion people playing video games worldwide, the overwhelming majority of whom wouldn’t exhibit gaming disorder symptoms. “There’s no curiosity whatsoever about the positive side of the coin,” Prof. Przybylski said. “Let’s assume the negative side of the coin is 1% of players, which might be a massive overestimate: what’s going on with the other hundreds of millions of people?”

We also spoke to Dr Henrietta Bowden-Jones, Director of the National Problem Gambling Clinic, and the Spokesperson on Behavioural Addictions for the Royal College of Psychiatrists. She is due to launch the first NHS clinic for behavioural addictive disorders related to internet use, the Centre for Internet Disorders, within CNWL NHS Foundation Trust, aiming to see people with gaming disorder from this autumn. Dr Bowden-Jones was delighted at the inclusion of gaming disorder within ICD-11, in terms of the progress that she believes this will drive: “Having the clarity of thought to be able to start screening for and identifying problems, now the problem is recognised, will lead to skilling up of enough professionals for countries to have dedicated services where people and their families can go to get help.” This echoes the hopes of Higuchi et al (2017), who, since opening a clinic in Japan for “internet addiction” in 2011, have been unable to keep up with treatment demand.


The kids are (not?) all right

Epidemiological research on problem gaming is currently fragmented, generating wildly different prevalence figures worldwide. Beyond cultural differences in prevalence of gaming and in attitudes towards people who play games, these disparities are in part due to the lack of consensus on which diagnostic tools to use and at what threshold problem gaming becomes a true disorder. The WHO has been trying to reassure the gaming community that gaming disorder affects only a “small minority” of gamers. Meanwhile, experts including members of the Substance Use and Related Disorders Working Group for ICD-11 expressed that Aarseth et al were missing the context of Asia, where prevalence of gaming disorder has been found to be higher (Saunders, 2017).

Dr Bowden-Jones said the next step forward was to develop a screening tool that could be used worldwide, to obtain prevalence figures that “make sense.” She noted that once we properly understand the scale of the problem, that can “lead to commissioning of research in areas that are less understood, and research in terms of outcomes, and to randomised controlled trials once treatment has been identified.” These are all good things that, she said, wouldn’t be possible without the disorder being recognised. Though even a prospective disorder classification can spur research, as seen with studies from the past few years based on the DSM-5’s IGD criteria.

One thing Dr Bowden-Jones doesn’t expect to uncover from unified prevalence studies is some hidden epidemic. “The numbers of people significantly suffering with the kinds of symptoms listed in the ICD-11 won’t be great,” she said. Her National Problem Gambling Clinic has been open for ten years, and has seen thousands of patients. “I can’t imagine seeing thousands of gamers.”

We tried our luck: what does she think the actual prevalence of gaming disorder is? “It would just be speculating,” she said. “If you asked me to have a guess, I would expect with correct screening tools, it should stay under 1% of the population. If it was higher than that, according to ICD-11 criteria, I would be extremely worried and I would be questioning what is happening in terms of the makeup of these games.” It makes sense: if gaming disorder was truly affecting 1% of people, then the average secondary school would contain nine pupils with significant impairment due to gaming.

Dr Bowden-Jones’s hopes for improved research are shared by Griffiths (2017), who agreed that current data samples in gaming disorder research are too small, but felt a robust and officially recognised diagnostic framework would surely help increase clinical sample sizes. But it has been suggested that by defining gaming disorder this early, research will be locked into a confirmatory approach (trying to find evidence for and understand a disorder, bound by established criteria) rather than an exploratory approach (trying to understand problem gaming from an open perspective) (van Rooij, 2018). “We’re going to miss the chance to actually learn something,” Prof. Przybylski said. “We’re not going to learn anything about the phenomena and we’re just going to stigmatise it.”

Gaming disorder is the only new disorder due to an addictive behaviour to be added to ICD-11, joining gambling disorder. There may be more addictive behaviours (dancing and tanning, for example), but research into these is scanty, and there doesn’t appear to be demand for treatment (Billieux, 2017). Is the behaviour of gaming getting all the attention because of societal stigma? Surely parents would have no issue if their kid was equally into football? “I think it’s all about loss of control,” Dr Bowden-Jones said. “People all over the country are gaming for a lot of hours and nobody’s minding. The ones who are coming forward clinically are the ones where the loss of control has led to direct harm or loss of quality to the young person’s life. If you were playing football five hours a day, that would be okay if you were still getting your homework done and still going to school. If, instead, you ended up missing a year at school, it would not be fine and one could argue this would be some sort of compulsive behaviour and the reason for that would need to be uncovered.”

Much has been made of whether a behavioural addictions framework was the right approach to problem gaming (Király, 2017). After all, the ICD-11 descriptions for gambling disorder and gaming disorder are essentially identical. Dr Bowden-Jones does see the similarity, but notes that gambling disorder can have far more visible harms in terms of money loss. Clients with gaming disorder, often younger and living at home, are less prone to these risks. “So when you’re trying to measure harm you really have to look at loss of control,” she said. This means a look at how the person’s life is impacted. “A lot of them drop out of school or their grades completely slip or they end up losing their friendship groups, becoming isolated. These kind of things indicate that a recreational activity has gone too far.”

The ICD-11’s description of gaming disorder does diverge from substance use disorders in certain ways: for example, there is no mention of tolerance or withdrawal, as it remains unclear if these are indeed common and consistent features of gaming disorder (Saunders, 2017).


Don’t panic!

The media of course has run full force with sensational stories of children enraptured by virtual worlds. Such panics are nothing new; two years ago it was Pokémon Go that had everybody worried. But it goes back even further. Prof. Przybylski directed us towards a clinical report (Schink, 1991) featuring cases of “Nintendo enuresis” - boys so transfixed by Super Mario games they would wet themselves rather than visit the bathroom. The problem resolved, according to the report, once the boys “learned to use the pause button.”

Delving further, Prof. Przybylski told us about a phenomenon Wallis (1997) documented during relative youth of the internet. A psychiatrist, Dr Ivan K Goldberg, had effectively dreamed up a diagnosis called “Internet Addiction Disorder” to parody the complexity and rigidity of the DSM. He was alarmed, however, to find people were in fact identifying with the hoax disorder, one symptom of which was that “important social or occupational activities are given up or reduced because of Internet use”. He then re-named his disorder to “pathological Internet-use disorder”, to remove any notion that the internet was an addictive substance. “If you expand the concept of addiction to include everything people can overdo,” Dr Goldberg had said, “then you must talk about people being addicted to books, etc.”

Could it be, then, that we are seeing cases that are more related to media panic than genuine pathology? “You can’t add to the prevalence just because people are worried,” Dr Bowden-Jones stressed. “You have to have cases. The cases need to have to have had the problem for at least a year, which is a long time.” Gaming disorder isn’t about people who dedicate themselves to a game for a few days in order to beat it. “I would not include those,” she said. “I don’t think any professional would do that. I would accept that some people need that challenge. So if the prevalence is high, it will be high because we’re seeing people who are struggling because of an activity.” She acknowledged that the ICD-11 criteria does allow diagnosis of gaming disorder if the problem has persisted for less than a year, if the problems caused are severe enough (though we note that what qualifies as “severe” isn’t defined).

The specific language of the ICD-11 requires that there be “significant impairment in personal, family, social, educational, occupational or other important areas of functioning”, which Billieux et al felt guarded against over-diagnosis: if there is no functional impairment, there is no disorder, no matter how much time is spent playing games (Billieux, 2017). Concerns about over-diagnosis form part of broader worries in psychiatry about patholigisation of normal behaviour. Prof. Przybylski also feels over-diagnosis is a possibility, noting the ICD-11 criteria are vague and lack specificity. Looking at the broad criteria, it does seem vital that clinicians should be aware of cultural norms of gaming behaviour when deciding if the behaviour is pathological. There are doubts that clinicians would limit the diagnosis appropriately if faced with a “highly engaged” gamer with no functional impairment. Furthermore, society’s labelling of highly-engaged gamers could be even less discretionary, again highlighting concerns about the stigmatisation of gaming behaviour (van Rooij, 2018).

When it comes to the possibility of stigmatising problem gamers by labelling them with a mental disorder, Bowden-Jones referred to her experience with gambling disorder: “It’s been helpful to my patients to know that their behaviour is indeed recognised as an illness; that they’re not evil people taking money. They never took a penny until they developed the illness, so why are they now stealing? I think it’s helpful, but there are two camps and it depends who you speak to.”


What’s really going on?

While accepting that people can have problems in their lives associated with intense gaming, van Rooij (2018) questioned if gaming was truly the cause of those problems (correlation does not imply causation). Indeed, perhaps problem gaming is a coping mechanism for underlying problems. Dr Bowden-Jones readily states that gaming disorders don’t seem to exist in vacuums: “The cases I have seen that have been significantly debilitating have either been in the context of a family with addiction there, or within the context of existing vulnerabilities in terms of comorbid psychiatric illnesses, or a family that has been disrupted or fragmented by change, whether it’s a death or a separation of parents, or domestic violence: something that the child is taking a refuge from.”

This of course made us wonder: if gaming disorder exists within this bed of existing vulnerabilities, can it be considered an entity in itself, and not merely a behavioural response? “That’s one of the interesting things about behavioural addictions,” Dr Bowden-Jones said. “These people are gaming 10-14 hours a day; that is the thing they can’t stop doing. If they didn’t have the vulnerability, they wouldn’t be doing it, but that probably goes for all other addictions, like problem gamblers. Half of the pathological gamblers we see have a first degree relative who was a gambler, so we are talking about vulnerability for sure. And we are talking about availability, because if they didn’t have the product, they wouldn’t be doing it. So there are issues there.”

When we asked Prof. Przybylski about comorbidities, he discussed his team’s research findings: “Psychological need deprivation--feeling incompetent; feeling unconnected socially; feeling like you can’t make good choices that reflect your values--is intertwined with problematic gaming.” He took the example of someone with problematic gaming behaviour who also has social anxiety, perhaps using an online game world as graded exposure to social interactions. “If there was a correlation between social anxiety and playing World of Warcraft, like Occam's Razor, I would assume that’s the reason such a correlation exists, and not because there’s something about the game that causes social anxiety: that would require some giant influential mechanism in the game to influence someone’s behaviour.”

However, a presentation preceded by depression or anxiety is not necessarily what Dr Bowden-Jones is seeing in her clinical practice. “When I have met people there appears to be, on the whole, some vulnerability there,” she said. “However, what parents are saying is: ‘My child was driven to success with sports, with academia, and now he’s driven to success with games.’ So what they’re saying is ‘you’ve got it wrong, you’ve got to listen to us.’ We’re seeing children who don’t have comorbidities, essentially. With problem gambling, there are several routes in, and it could be that we’ve got several routes in to problem gaming.”

We don’t know much about the biological underpinnings of the disorder, though Dr Bowden-Jones believes that there is certainly something there: “Interestingly, we are seeing gamers whose parents might be pathological gamblers or have alcohol use disorders, so there is that vulnerability towards excessive behaviours. There is a genetic vulnerability there, for sure. Maybe it’s just being uncovered earlier because the young person is doing something that gives them the potential to manifest this behaviour in a way young people didn’t have, before.”

There remains a lack of clarity on what the nature of gaming disorder is, in terms of what kind of games, or what game mechanics, are implicated (van Rooij, 2018). Prof. Przybylski voiced similar concerns: “I would want to know what the ‘cannabinoid’ in the game would be, which would be able to cause, or interact with something to cause, these problems. That would be a very big active ingredient that we’ve never stumbled upon before. I feel like if that thing existed, all the games would do it. All cannabis is more similar to all cannabis than all games are to all games. So I would think that games would homogenise in the way fixed odds betting machines have homogenised… but it clearly hasn’t happened.”

We asked if he’d consider that there was something addictive about games, more addictive than there used to be years ago, even if we have not yet honed in on what that is. Prof. Przybylski prefers to think of games becoming more attractive, and more accessible. “You don’t need a very expensive computer or dedicated console to play them, anymore,” he said. “We have computers in our pockets. You don’t need to drop £60 to get into a game; many games start off as free.” Because of their ubiquity, games are more able to dominate our social time. Gone are the days of arranging a date to play games with your friends. “Because of our phones it can happen anywhere,” he said. “There’s definitely an aspect of social pressure to it; it’s the hip thing.”

It’s no secret that video games companies themselves actively try to attract players, of course: “A lot of games have some pretty problematic business models,” Prof. Przybylski said. “Really, the revenue of many free-to-play games is dependent on extracting a lot of money from a limited amount of players.” And video game companies actively encourage players to stay in their world. “If you deactivate your World of Warcraft account, Blizzard reminds you that you haven’t played for a while and sends you pictures of your avatar, and that kind of persistence is new. As a scientist, I find that something to be interested in; something to study. My first reaction isn’t ‘how does that relate to psychopathology?’”

Dr Bowden-Jones, for her part, is all-too-aware of how broad-brush a term “video games” is, when it comes to thinking about what could be addictive about them. It seems hard to imagine that a game such as Ico could have the same potential for disordered use as a game such as Candy Crush. However, she sees opening the gaming disorder clinic as the first step in understanding this medium. “Are some products more harmful than others?” she asked. “In a year’s time, we might be able to discuss those findings: what are the games that people struggle with and what are their features?”

Perhaps the key question to this whole issue is whether or not a video game can be addictive in the pathological sense. Prof. Przybylski does not see convincing evidence for this, but stresses that absence of evidence is not evidence of absence. Whatever evidence currently exists does not meet the threshold he would set for formulation of a disorder, and he feels psychiatrists are jumping the gun. Whatever their stance on gaming disorder, all experts seem united in pushing for better research. Prof. Przybylski's camp in particular have stressed the importance of transparency in studies, including pre-registration of hypotheses and plans prior to data collection. “It’s the Texas Sharpshooter fallacy,” Prof. Przybylski said of gaming disorder research, referring to the process of forming a hypothesis after the results are known. “They draw the target on the side of the barn only after they’ve sprayed it with the machine gun.” Additionally, he feels a lot of valuable data is held by video games companies about how players engage with their games, but companies don’t share this data. “These companies need to do transparent, open, and reproducible science. I think that if they plan on surviving the next 20 years, it will happen.”


A chance to offer help

Dr Bowden-Jones acknowledges that the field is “definitely divided” when it comes to gaming disorder. “There will always be controversy about classification,” she said. “My line on that has always been: provision of services and provision of instruments will be facilitated.”

In many countries, treatment can be funded through health schemes, e.g. insurance companies, only if the condition being treated is a recognised disorder (Van Den Brink, 2017). While official recognition may reduce many barriers to treatment such as service provision and affordability, Prof. Przybylski warns that we as a profession remain in the dark about treatment. “When anybody talks about technology addiction like it’s a real thing,” he said, “if you get them to tell you what the treatment should be, you learn everything they don’t know. They say things like: ‘stop play’. Or for smartphones: ‘make your screen grey’. Or they say: ‘cognitive behavioural therapy’.”

Prof. Przybylski is aware that some academics are already suggesting medicines which may be of use in the disorder, though he notes the evidence simply isn’t there yet to make such recommendations. “So already you have people rushing to manualise pharmacological intervention for an aetiology we don’t understand… The thing I’m worried about is psychiatrists and psychologists going on a crusade on this topic in a similar way to their pursuit of violent games. But instead of being about whether or not games can be sold to under-18s, this is going to be about Prozac prescriptions. And so the stakes for young people are much higher.”

Bowden-Jones’s own view on pharmacological management is fairly conservative: “With good evidence based treatment, such as CBT delivered on a weekly basis, whether it’s online treatment or face to face, abstinence or moderation can be achieved without going down the route of medication.” We asked about Prozac, and she replied “I can’t see SSRIs [a class of antidepressants including fluoxetine/Prozac] helping, to be honest. I might be wrong; don’t forget that just because it has some similarities with gambling disorder, that doesn’t mean gaming disorder is identical. But let’s say that there was significant similarity: we already know that SSRIs have not given us the answer in pathological gambling, unfortunately. Very little is helping enough in terms of pharmacology.” She did mention specialist use of naltrexone within her gambling clinic with adult patients who are resistant to psychological therapy, but it remains to be seen whether that medication has a role in treating gaming disorder, and she can't foresee its use in people under 20.

While Dr Bowden-Jones doesn’t deny that research on gaming disorder is in its early days, she does speak from personal front line experience. “I’ve met with a young person this morning whose mother was desperate for a diagnosis,” she said. “They had dropped out of school and done nothing else for months. This person is roaming around without a diagnosis and yet suffering every single tick on all the criteria. This kind of example makes me feel that this is about trying to do the best you can for a population of young people and families.”

One thing both camps agree on is that there are indeed a small minority of gamers who exhibit problematic gaming behaviour. Given that Prof. Przybylski is not convinced that this represents a disorder in itself, what does he feel the message should be to a concerned player, or a concerned family member? “Subjectively, in terms of things we know from self-reports, people who play video games aren’t necessarily having fun,” he said. “If they’re playing games out of a sense of compulsion, not out of choice, they tend to have both positive and negative feelings about games. So we need to be making sure that the paths of communication between parents and kids are open, not treating games or technology like a black box, and making sure that there’s an environment that is rich in terms of need satisfaction. If what we’re really dealing with is a specific instance of behavioural dysregulation, then we need to leverage what we know about helping people on a subclinical level to better regulate themselves, and that means better environments that foster human thriving. There’s certainly a lot of indirect evidence that people’s behaviour around gaming can become disorganised. Absolutely. There’s far and away enough clinical reports and anecdotal reports. So the thing we have to do, as scientists, is be able to distinguish between that observation and what the WHO and the research literature tries to sell us, and those are fundamentally mismatched propositions.”

On the other hand, Dr Bowden-Jones’s approach for these minority of gamers is to offer assessment and treatment. She hopes for the Centre for Internet Disorders to be an NHS hub where a lot of research takes place, where training can happen, clinical work, and for there to be a few satellite units for engagement with clients across the country. “We need to make the treatment accessible,” she said. “I envisage there will be a significant component of the treatment that will be online.”

She’s still in the early stages of forming her new clinic. Regarding expected treatment demand, she said “I have no idea! When I started the gambling clinic, people at the Royal College told me I’d probably see about thirty people a year. And now it’s many hundreds a year coming to us, requesting help. Our referrals over the last decade have frequently been at around nine-hundred and with these gamers I think this could go one way or it could go another. It could be the quietest service we’ve ever seen. I’m not in favour of sensationalising. When I speak to the media I’m always clear it would be damaging to everybody if they were to sensationalise something without the facts. And we don’t have the facts because we don’t have any good research on gaming disorder in this country. So all we can do is say we feel that due to the ICD-11 decision, and because of the requests we’ve had, we feel a clinic is needed. Then let us see: are there enough people? Are they showing up? And what works?”


A tale as old as psych

We came away from these discussions thinking about the overlap between the two camps, and what they seem to agree on. Nobody really denies that there exists a small minority of gamers who exhibit problematic play. Both sides suspect the prevalence must be very low. Both agree that the presentation of problematic gaming can be associated with underlying factors that increase vulnerability to that behaviour. There is even agreement that, in terms of evidence, we’re simply not where we need to be, yet.

What seems most apparent in this schism is a matter of philosophy: whether our medical classifications, which have historically had huge positive and negative impacts on individuals and society, should be underpinned by gold standard evidence, or if a pragmatic approach of ‘classify now and find the best evidence later’ is warranted in an aim to reduce suffering. Neither is a simple option and both have their problems. If the ICD had a section for prospective disorders in need of further research, or if decades didn’t pass between editions, perhaps there would be an easier path.

This is a problem of medicine, and more so this is a story of psychiatry, a discipline in which our understanding of conditions develop in tandem with how we treat them. A discipline in which diagnoses have come and gone, some relinquished back into the realm of healthy human behaviour. But some diagnoses do stick, and some evolve. One wonders, when they look back on gaming disorder, what medical historians will say, blessed with hindsight.


Authored by Sachin Shah and Stephen Kaar



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22/05/2018 14:26:46

VR to reduce anxiety of young patients

In this blog by Sin Fai Lam, Constantinos Panayi discusses virtual reality to reduce anxiety and isolation of young patients, his projects and hopes for the technology.

Admission into hospital for children can often be an intimidating process. The potent mix of being in an unfamiliar environment along with the uncertainties of the unknown can lead fear and uncertainty. Furthermore, if children receive insufficient information regarding the various procedures within the hospital, they may experience elevated levels of anxiety 1. 

In one particular area, attempts have been made to alleviate this distress. Magnetic resonance imaging (MRI) scans can be intimidating, due to the nature of the procedure with its loud noises, large machine and relatively confined space. Some children find it hard to tolerate such a procedure and this sometimes necessitates the scan being conducted with the child under sedation, which is not ideal. Therefore attempts have been made either via mock MRI scanners2 or via virtual reality (VR) mock-ups3, to help prepare children for the scan, with initial evidence suggesting they have a benefit in reducing agitation and anxiety.

I was fortunate to attend a Middlesex University end of year showcase and was able to interview Constantinos Panayi a 3D Environment Artist specialising in VR Technology who was collaborating with Great Ormond Street Hospital (GOSH) in developing a similar VR mock-up for them. The aim would be to use VR to show the child the MRI procedure and in the process help the child become aware and informed. In theory, this should be a more informative experience than simply receiving a verbal description of the procedure from healthcare staff. This in turn would hopefully reduce the child’s anxiety before the scan.
Constantinos explained his initial inspiration:
“I was initially stuck for ideas on what to do for my final year project,” he said, “however my teacher mentioned that his friend had an MRI scan once, then I got thinking about showing an MRI procedure in VR. I had spent many years in Great Ormond Street Hospital and I remembered how stressful the whole experience was. I had many MRIs and CT (computerised tomography) scans and I could remember the noise and being alone in the room by yourself. It can be quite daunting. I then decided to read up about MRI and to research more on it. I was able to find information online and was able to talk to the people in the hospital who agreed for me to look at the machine.”

VR image of MRI scanning environment

The child is presented with the MRI scanning environment, while additional elements animate the scene


Constantinos then developed and designed the VR model. He drew inspiration from the video game “That Dragon, Cancer” and designed the mock-up with a similar “low-poly” look to that game (“low-poly” refers to 3D objects being constructed from a relatively low number of polygons, which can result in objects having a clean, blocky aesthetic; an intentional stylistic choice). He integrated additional features to the VR model, such as having visual stimulation like fish swimming within the model to allow greater engagement for the child and to reduce the intimidation of the entire process. 

Discussion with Clare Simcock, the lead radiographer for GOSH, also highlighted how the joint work between individuals with different expertise helped to develop a more polished product. Claire said “Constantinos approached us about this project and it was something which we were interested in.” She highlighted how the team fed back regarding the technical aspects of the procedure as well as regarding visual considerations. This included considerations for younger children and children with special needs and how they would interact with the environment.  However she did note that this project was still a work in progress and further research is needed into the field. 

Running concurrent with the MRI project, Constantinos was also developing a VR simulation of one of the gardens within GOSH. The idea being that patients would be sitting in the garden through the use of VR and it would ,“come alive through the use of animals and plants”. Additionally, “reassuring and thoughtful letters that have been written by former patients are brought to the table. A narrative then reads them out to the patient.”


VR image of a rooftop garden


VR simulation of GOSH’s Morgan Stanley Garden, designed as a virtual respite for isolated patients


Constantinos said “When I was a patient, I spent some time in isolation. I remembered that as a patient, I was not allowed to go out; I was not allowed to go outside. It can be very lonely. This is a relaxing garden” and he hoped that patients experiencing it in VR would help them feel less isolated, if only for a while.

I asked him whether he thought that children would be able to engage with the VR models. He felt that the visual nature of VR can appeal to young patients and he had seen children use it during his demonstrations at shows. Through their feedback he found that they felt happy and relaxed. Constantinos stated the ability to immerse the child in the VR world was another important factor. “On one occasion,” he said, “the young child pointed out to their younger sister ‘look look at the fishes’ whilst wearing the VR headset, and the sister replied, ‘but its not there, only you can see it.’ The smiles and their looks just made me feel it was worth it.”

Constantinos continues to be actively involved in GOSH both as a guide and as member of the GOSH Young People’s Forum, which looks at ways to make hospital life better for young patients. “I have spent much of my childhood involved with GOSH,” he said, “both as a patient and a sibling of a patient. It’s almost like it is my second home and I am giving something back to improve patient experience.”

Overall, I find Constantinos project exciting on two different levels. One aspect is the usage of technology to improve patient experiences. The promise is that VR technology could potentially be a non–pharmacological/low-risk method of reducing anxiety and distress amongst children in hospital. However, what I think his project highlights even more is the need for hospitals to engage better with patient and relative groups in trying to improve experiences within our services. Patients often have their own unique experiences of healthcare services that clinicians may not always be aware of. Projects like this help bridge that gap of knowledge and allow us to work more collaboratively in achieving desired outcomes.

References1. Wilson, Margaret E., B. S. N. Kimberly Carlson, and B. S. N. Laura Enenbach. "Children's Experience of Hospitalization." The 18th International Nursing Research Congress Focusing on Evidence-Based Practice. 2007.
2.  de Bie, Henrica MA, et al. "Preparing children with a mock scanner training protocol results in high quality structural and functional MRI scans." European journal of pediatrics 169.9 (2010): 1079-1085.
3. Liszio, Stefan, and Maic Masuch. "Virtual Reality MRI: Playful Reduction of Children’s Anxiety in MRI Exams." (2017).

26/03/2018 10:09:10

Stuart Duncan's Autcraft: crafting a playspace for children with autism

Under the name @AutismFather, Stuart Duncan shares his experiences of parenting an autistic child and his opinions on “all things autism”. He remembers Minecraft’s meteoric rise in 2012 not only as a dad playing the game with his two children, but as someone connected via social media to many other families with austistic kids. Initially, parents would share that their child “would do nothing but play, watch and talk about Minecraft”. However, more serious frustrations emerged: parents increasingly reported their children were being bullied while playing Minecraft on public servers. Stuart responded by creating a server where autistic children could meet up and play together safely – and so Autcraft was born in 2013. We spoke to Stuart about Autcraft and its potential lessons for other gaming communities.


How it works

Minecraft is an absurdly successful 'sandbox' computer game with over 144 million copies sold, making it the second best-selling computer game of all time (behind Tetris). The gameplay is akin to playing with Lego, but in a procedurally generated world full of dangerous beasts. Generally, there are no explicit goals and players are free to create as they wish.

The Autcraft server hosts online games of Minecraft, and players must undergo an application process to be able to play on it. On the server there is zero tolerance for bullying, swearing or stealing, and a structured system exists for praising positive behaviour. The server also uses plugins to ensure that structures players have built can’t be destroyed by other players. At its core, Stuart and a team of admins ensure the community functions effectively. Stuart feels that the diversity in the admin team is one of the server’s great strengths. Stuart himself brings a wealth of lived experience to running the server as an austistic person and as a parent of a autistic child, but he recognises that he cannot relate to every situation, and so he relies on the diverse admin team to better represent server users. The admin team include parents of autistic children, some of whom are autistic themselves. 

Team of Autcraft admins

Team of Autcraft admins

Admins deal with various issues that arise, including reports of real-world bullying and suicidal thoughts. The response is to try and match up the player in question with someone they can relate and talk to. Admins have often had similar experiences themselves, plus other server users may be going through similar situations at that moment in time. At the most fundamental level, Stuart says “we just let them know that they're not alone… We're here for each other and will support each other for as long as need be... we all know how terrible it can feel sometimes and none of us want the others to feel that same way.” As an illustration of this, Stuart remembers users who initially came to the server feeling suicidal and are now helping others dealing with similar situations. 


Positive outcomes

Stuart aims to help players flourish by providing “an accepting environment where they're not afraid to learn, grow and make mistakes.” He feels many servers focus on gaining a high volume of users, to the detriment of fostering a supportive community. In an online world where ‘griefing’ and verbal abuse are rife, Stuart feels it is a shame that Autcraft is an “anomaly” with its supportive ethos, and he hopes that the server can demonstrate to others that it is possible to achieve large user numbers whilst also working to lock out abusive behaviour. 

Stuart describes a number of examples of Autcraft users flourishing. He recently finished writing an employment reference letter for one of Autcraft’s teen players (who has the rank of ‘Helper’ within the game), and he recalls other players who have obtained their first jobs following on from their experiences with Autcraft. Parents often get in touch to say their children are making friends at school after playing on the server and “learning how to interact with others.” And players themselves describe doing things they never would have done before playing on Autcraft: “one child said he helped an elderly lady with her groceries at her car just because it's the type of thing we encourage players to do on the server.” The server also provides a supportive space for users to develop, such as “the kids who sign onto the server and don't say a word for months, but, once opened up, become so helpful that they are rewarded with a rank and a position that allows them to help people”.

The 'Autcraft Lodge'

The “Autcraft Lodge”

It is not only autistic children and their families who are open to the benefits of Autcraft. Researchers have taken an interest in how the server works as an assistive technology for youth with autism. Stuart has also found that a significant number of players heard about the server from a healthcare or education professional, which he sees as an encouraging development from the perhaps traditional attitude that video games are stultifying. Professionals appear to be “open to the good that a server like Autcraft can do” and are beginning to appreciate “the benefits of a community at play”.


Lessons learned

Stuart has been exposed to negativity and abusive behaviour surrounding autism himself, but also second-hand through Autcraft, as players share experiences of bullying on a scale he hadn’t anticipated. “It can feel like the world is still a very dark place with a long way to go,” he said. He has also found that autistic people are struggling with issues such as sexuality and gender identity which are not always well-recognised.

Stuart describes learning about the fears that can hold back users in their daily lives, “the fear of being judged, teased, mocked, bullied or even the fear of being alone… On Autcraft, I've seen children sign on, totally in a panic at this new place with new people and having to speak and worried about breaking things and being punished… and I've seen those same children learn to let all of that go and share their likes and dislikes, their dreams and their heartaches with everyone else… I see children making friends for the first time ever, I see them becoming interested in science because some other child is making it sound like magic.” 

Autcraft players assemble

Autcraft players assemble


The future

Stuart notes that Autcraft is becoming increasingly well known as a positive group, and other things are changing for the autism community. Autistic characters are being featured in television programmes and awareness campaigns are increasing. Some Minecraft servers now ban players for hate speech if they use the term “autistic” as a form of insult. Stuart ultimately feels optimistic that people are more open-minded to understanding autism.

Autcraft is a way of life for Stuart, which comes with long hours and full-time dedication, which amounts to being “patient and compassionate and understanding and positive each and every time” he is needed. Looking to the future, Stuart is working on a secondary server that will allow players to play in “Creative Mode”, with access to unlimited items and materials for unrestricted building, as opposed to the more traditional mode where players must first gather materials in order to build. If funding were no obstacle (Autcraft relies entirely on donations), Stuart’s dream is to be able to offer Autcraft in other languages and add servers in more locations. 

Stuart Duncan (AKA AutismFaher) in Autcraft

Stuart Duncan, AKA AutismFather

As a veteran gamer, what does Stuart play when he’s not working on Autcraft? “I’ll always love the open-world games that I can play at my own speed. Zelda: Breath of the Wild, Watch Dogs, Assassin's Creed, GTA…” He views video games as a way to relax and de-stress, providing vital “me time”, and he finds doing his own thing within a game satisfying and freeing. “I can take my time and build at my own speed. If I want action, I can go find that. If I want to fish, I can do that too.” For him, this is Minecraft’s appeal, and Autcraft simply takes this one step further by allowing this freedom within a well-supported and structured environment.

More information on Autcraft is available through the official website.

Authored by Fran Debell (Core trainee in psychiatry, South London and Maudsley NHS Trust). Interview by Donald Servant.

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

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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.