In 2017, a video game called ‘Hellblade: Senua’s Sacrifice’ was released onto PC and Playstation 4. The game was a particularly pivotal moment in the development of video games as a vital medium of art, and as a beacon of representation. The game also lead to it’s developers believing video games could go beyond an entertainment experience, they could be utilised as a therapeutic experience.

The game developers of ‘Hellblade’, Ninja Theory, made the bold choice of creating a main character, that the player manoeuvres through the world as, who has psychosis.

Upon deciding to make Senua’s (the main character) mental health a focus in the game and a part of its mechanics, Ninja theory consulted with leading neuroscientists, organizations such as Wellcome Trust – who actually put them in touch with people who live with psychosis – and experts on voice hearing to create an experience for the player that was as close to how auditory hallucinations are experienced in real life.

Whilst interviewed for the in-game documentary, lead writer and Director for Ninja Theory, Tameem Antoniades said of the choice to have their hero of the story experience psychosis “Games are capable of drawing you in for hours on end, playing the role of a character who’s different from you, experiencing their perspective, and actively involving you in a world that functions with a different set of rules.”

Antoniades is quick to admit his own ignorance and preconceived ideas about what psychosis is for those who experience it and noted in a piece on ‘Hellblade’ for Science Focus that he “learnt that people can experience hallucinations and delusional beliefs without it being a problem – the illness comes when those experiences cause suffering. Often recovery is not about curing yourself of hallucinations, but finding ways to live with them. That was a revelation to me.”

For the same Science Focus article, Professor Paul Fletcher from the University of Cambridge said, “It’s been refreshing to see a representation of psychosis in which the person isn’t just a sort of passive receptacle for madness. Senua is the hero of her own story…that’s incredibly de-stigmatising.” Prof. Fletcher goes on to say, “the character is fully-formed, and they are not defined by their condition.”

In June of 2020, during the midst of the COVID-19 pandemic the much awaited ‘The Last of Us Part II’ was released. Before it’s release there was a lot of discussion from within the gaming community about the inclusion of a trans character and that the main character from the first game, Ellie, was revealed to be gay.

Unfortunately, this resulted in a lot of backlash from many people. However, for people from within the LGBTQ+ community, this was a breakthrough moment of representation within gaming.

Aubrey Anable, a professor of film studies at Carleton University in the US spoke to this on the BBC Iplayer documentary ‘Gaming and Me: Connections, Identity and support’. Prof. Anable explained how games were, for a long time mostly played by white, hetero men and acknowledged that yes this is a stereotype, but it’s for a reason.

For decades the white hetero, cis man was who games were marketed to, who they’ve been designed for. But ‘The Last of Us Part II’ broke this pattern in the main stream and as a result it has meant a lot for women and people within the LGBTQ+ community.

Abby, a gamer who appears on the same BBC iPlayer documentary discusses this representation through the character, Ellie. Abby is exploring her own gender, identity and sexuality as a young person and seeing a character like Ellie, or the trans male character of Lev has given them a sense of belonging.

Abby also speaks on the representation of mental health and illness in the game, saying that that the heavier themes of loss, trauma, grief, revenge and anger have caused them to self-reflect, saying “it’s better to deal with stuff as soon as possible rather than letting it dwell because then you get lost in it, and you watch that happen to Ellie”.

Community, friendships and support

Another side to gaming that an Oxford University study actually investigated, is the presence of communities in gaming, particularly in games that allow for chat functions.

Elissa, a gamer on the BBC iPlayer documentary talks the viewer through how ‘Animal Crossing’ has helped them cope with the isolating affects of the lockdown and COVID-19 restrictions. They speak about how the menial but soothing administrative tasks that are part of the game mechanics intrinsic to the ‘Animal Crossing’ experience, helped to simulate daily routine and chores, in a reality where all they had was their university dorm room.

Jordan Eirca Webber, a video games expert said of ‘Animal Crossing: New horizons’ that it “inspires community”, giving people the option to connect with friends virtually, invite people to events, and even engage in exchanging items, something which has been set up via Facebook groups so that people can attain the items, objects or resources they need without necessarily ever having to spend more money.

It is easy to understand how being able to take part in activities such as these in ‘Animal Crossing’, especially during lockdowns and periods of time where schools and universities have been closed, could boost mental health.

In the iPlayer documentary, from her university room, sat alone, Elissa is able to throw a Halloween party on ‘Animal Crossing’ for themselves and their friends, as the party goers turn up to the space in-game, there’s a real wholesome feeling. Elissa chats to their friends and enjoys the closest thing to a ‘normal’ Halloween that they can get.

A prominent voice in the documentary for advocating mental health and gaming is Joe Donnely, who wrote an article in 2019 about is experience of finding a mental health support group in one of the most unlikely gaming spaces, ‘Grand Theft Auto’ (GTA).

The particular incarnation of the game Donnely refers to in the documentary and in his article is ‘Grand Theft Auto V’, in which role-play servers were added for PC gamers in 2015. This role-playing addition to the game allows people access modifications to the game or ‘mods’, that allow users to work, live, socialise and even engage in voice chat.

The world mimics the real in as much that you are expected to carry out your jobs, obey laws enforced by voluntary police (other role-players) and hugely differs from the violence and crime usually associated with the game.

By complete happenstance, Connely stumbled upon a group of other role-players gathered at the top of a mountain above the fictional GTA city of San Andreas. During this meeting he heard a gamer, pseudonym Craig, open up about his mother’s alcoholism and then subsequent death.

After this initial encounter, Connely joined the in-game support group multiples times after, eventually speaking about his own struggles with mental illness.

In his piece on the Guardian, Connely speaks on the anonymous yet supportive environment of the GTA live, voice chat saying “video games are uniquely placed to help people explore the kind of sensitive and interpersonal issues that can be hard to face up to in real life”.

Could video games be used therapeutically?

The same game developers from ‘Hellblade’ recognised an opportunity to take the simulated experience of mental illness from that game and apply it for therapeutic purposes. In 2019, they launched the Insight Project, in conjunction with Cambridge University.

The project combines technology, design and clinical neuroscience to create prototype games that can measure heart rate, breathing and even eye movement.

The hope from Ninja Theory and the team behind the Insight Project is that story-led challenges in games that force the player to be mindful of things such as heart rate could potentially lead to these games being helpful in the treatment of disorders such as anxiety.

Tameem Antoniades from Ninja Theory spoke to Microsoft about the potential behind this kind of video game therapy, “what clinicians often lack is the technology that can create context, as well as access large numbers of people”.

Ninja Theory and the Insight project have big ambitions to make the mainstream, so that people, whether they’re diagnosed or not, can engage in gaming to help manage or control their negative mental health symptoms.

Whether it’s providing a unique experience of representation, a community of people who can support one another or even going so far as providing therapeutic solutions; gaming is a source for wellbeing and mental health that should no longer be ignored.