Games for Mental Health: Six Case Studies, Part I Depression Quest: Increasing Empathy for Social Impact


David Seelow, Ph.D©

          Depression Quest is an interactive fiction that helps people gain a better understanding of clinical depression. This serves a dual purpose. For one, people who encounter a depressed individual will have a clearer picture of what depression really feels like and, therefore, be more empathetic and helpful to the sufferer. Moreover, those who do suffer from depression may be nudged to seek help. The designer Zoë Quinn and her cowriter Patrick Lindsey both suffer from depression and the game does have an authentic feel because of this personal experience.1 At the same, the narrative carefully represents clinical depression in a more general fashion allowing many readers/players to identity with the story. As a free to play game or pay what you can pay, the game belongs in a special way to the game for impact category. What money is generated by the game goes, in part, toward National Suicide Prevention, giving the game a genuine impact on an essential mental health service.

          The game starts with a quote from the extraordinary American novelist David Foster Wallace who committed suicide on September 12, 2008. The quote is worth repeating.

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David Foster Wallace Quote from beginning of Depression Quest

Two things about this quote need foregrounding before thinking about the game. First, Wallace, a celebrity, suffered depression in the extreme.2 It is also worth noting the day Depression Quest was released on Steam, August 11, 2014, was the same day the incredible comedian and actor Robin Williams committed suicide. Clinical depression can hit anyone regardless of celebrity status, wealth, race, ethnicity, gender etc. Depression does not discriminate. The fact someone as vibrant, as funny and joyous in public as Robin Williams, a  person who could make any one laugh at any time, suffered such excruciating mental pain that he took his own life should give us pause.

          A second point about the quote that needs emphasizing regards the major difference between depression as understood by many, if not, most people, i.e. situational depression – having the blues, or breaking up with a lover, losing a friendship, and clinical depression which Wallace describes as “horrible.” A person suffering from clinical depression does not get through it or shrug it off. No way. Clinical depression is unrelenting, chronic.  Members of my family have suffered from such depression as have I. In my case the clinical depression carries the diagnosis of dysthymia (now called persistent depressive disorder- a continual feeling of being down) that requires much effort to overcome and, then, only for brief spurts. Success, money and the like do not remit this depression.3 It never, really goes away.

          When completing my doctorate, I worked for 3 years with the “mentally ill” and encountered both dysthymic clients, and those diagnosed as suffering from Major Depressive Disorder. Today other diagnoses have been added including premenstrual dysphoric disorder and disruptive mood dysregulation disorder (a disorder I only learned about recently). What matters for here is the more basic distinction between clinical depression diagnosed by a psychiatrist and situational depression. The much more debilitating clinical depressions have a biological aspect that generally requires medication in addition to therapy.  Medication for such sufferers is critically important, but even if compliant with medication (itself uncommon), the depression is simply managed not cured. Not taking medication can push the individual into a dark abyss.

          Quinn makes my above points with a very effective game refrain that acts like an authorial imperative. The two below are a recipe for disaster.

Screen shots of Authorial Imperatives that Operate as a Refrain in the Game Depression Quest.

These imperatives- by an omniscient narrator, act as a constant constraint- like a wall in other games, the limit off which an object will bounce, but not traverse. You can feel better- but within limits, and often not for long.

          In addition to these imperative refrains, Quinn uses the rare second person narration to draw the player into the experience of clinical depression. “You” are the player, the central character or protagonist of the game. In this way, the player embodies depression, and the identification with a depressed person’s daily activities and thoughts creates empathy; the empathy necessary to both understand and help a depressed person. Many people with clinical depression do not acknowledge their condition and therefore do not seek treatment.

          Quinn’s game address this sad- excuse the pun, fact, by giving the character you play relatively ordinary characteristics. You have a girlfriend, supportive family, friends and a job.  The girlfriend is named Alex, but “you” is never identified and could be any gender.  You can work, play, and function at a high level with depression, but joy is often muted- it’s mostly dysphoria not euphoria, your world is dystopian, not utopian. Many times, these daily activities, especially when not in treatment or taking medicine, are a struggle, even, over time, an ordeal. These struggles are reinforced by very negative thought patterns. For example, “Friday afternoon and Alex asks you to a pub and have fun but you ask her to come over and re-watch old movies- then feel guilty as you feel you are pushing her away.” No matter what choice you make or action you take your thoughts undermine that choice and cause self-doubt which can be crippling. The link between negative thinking and self-defeating behavior generates a loop enabling depression’s persistence, but thankfully this reinforcement can also be broken by cognitive behavior therapy. However, the depressed person must choose therapy and that does not always happen.

          Like all interactive fiction and choose your own adventure stories Depression Quest’s basic action consists of presenting a short narrative followed by 2 or 3 choices for the player/reader to select from. Each choice brings about a different narrative path that constitutes interactive fiction’s branching narrative style. This nonlinear narration allows for many different versions of the protagonist’s quest. This mechanism also gives the reader direct impact on the story resulting in multiple possible outcomes. Different players create different story lines, and you can also replay or reread the story and end up with a different outcome. Although the protagonist has some defined characteristics, a brother, a mother, girlfriend, job etc., different players will make different choices based on their own background. As someone who has suffered depression, I will make choices consistent with my experience, whether personal or from having been a social worker, whereas someone with no experience of clinical depression might make a different choice.

          In the below example, the protagonist has returned home from work feeling depressed and lacking motivation. Your girlfriend is at school and you dread the work you want to complete now at home.

Screen Shot of a Player’s Choice in Depression Question.

Each of the 3 choices are consistent with depression, but for me choice 2 makes most sense because I would want to be productive and believe I just needed a boost or jump start, so watching TV for a short time could rejuvenate me.

A screenshot of a cell phone

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Screen Shot: Result of the Above Player’s Selection.

          This choice has predicable results. The short time watching television turns into a long time vegetating in front of the screen. You feel guilty from doing nothing and when your girlfriend asks to talk- something most people might appreciate since talking takes you out of isolation, but you brush her off and that, in turn, makes you more depressed and guilty because you feel you have let your girlfriend down. The depressive spiral continues, and you can neither work nor sleep. That’s clinical depression.

          Also note that you have 3 active choices to make, but that 4 choices are listed with the first one crossed out. Quinn uses this simple but powerful mechanic of removing choices to enact how depression removes agency from a depressed person. The game’s mechanic perfectly enacts its content. A depressed person’s choices are more limited than those of most people. They just do not see certain options. In this case, the choice of “order some food, grab a drink, and hunker down for a night of work,” does not represent an option to a person suffering from depression. However, that would be an option, even a likely choice, for a non-depressed person, so seeing that crossed out option makes the player acutely aware of how depression affects one’s everyday choices. Depression limits your options, closes off possibilities, and gradually constricts your world, tightening around you like a Boa constrictor.

          Quinn also challenges game conventions another way. A quest generally suggests adventure, excitement, hidden treasures and heroic actions. In Depression Quest, the goal will be to keep going. No great treasures other than the treasure of functioning well day to day. Your weapons are not swords, clubs, guns and the like, but medication, therapy and friends. The ordeal is life itself. Thus, Quinn deflates the otherworldly quests of World of Warcraft and other epic games. She brings the quest down to earth, makes it real- not less heroic necessarily, but pedestrian.

Applying the Game

          As the design team states in their description of the game, “This game aims to show other sufferers of depression that they are not alone in their feelings, and to illustrate to people who may not understand the illness the depths of what it can do to people.” These dual objectives make the game appropriate for a very broad audience. I have used the game in a college class, and everything I do with the game would be appropriate for high school. Additionally, the game would be excellent for community mental health centers, school counseling centers, Parent Teacher Organizations, the Alliance for the Mentally Ill and related groups. An entire game can be played in between 50 minutes to a maximum of three hours, so assigning this game as a “homework” or a task, whether in a school or counseling center, makes sense.

          For homework, whether school or counseling based, a simple, but useful task is asking the student or “client” to keep a dual entry journal. One side records the choices made at each decision point and what led the person to make those choices. Following out the decision tree can be very revealing of both the realities of depression and one’s cognitive processing. The other column could act as a more affective journal- something like what literary critics call reader-response. Here the student/client records his or her emotional response to the same decisions. “How do you feel about watching TV rather than starting your project?” These are reflective exercises that also simultaneously address emotional learning and the more academic, cognitive learning. In a classroom or counseling session you can then help students think about how they make decisions. In counseling, the response can be talked about one to one which has tremendous therapeutic benefits.

          In a classroom or presentation to a parent or support group, I would play sections of the game. The instructor leads the game play by framing the game and then going through a couple of early choices and engaging whole group discussions at each decision point. Once the class or group has a grasp of how branching narratives work, I would ask members to make choices while I click the links and ask them to discuss their reasoning behind each choice. I continue the activity one student or parent/group member at a time for approximately 45 minutes. After 45 minutes ask students to reflect on their experience individually, while with a group of adults, you should reflect more collectively. Each time I have followed this procedure in a class the most common response has been an increase in empathy for a person suffering depression. The second person narration enables this empathy to a significant degree. Once there is an increase in empathy for the sufferer then the possibility for positive change in how such individuals are treated increases as well. When empathy and action coalesce, a game has made a positive impact and that’s a high quality game.

The National Suicide Prevention Lifeline is: 1-800-273-8255.

Notes

1. Many people reading this probably know that Depression Quest and Zoë Quinn were the ground zero for the #Gamergate phenomenon. For this blog, I am only interested in discussing the game on its own terms. However, I would like to mention that out of that tragic morass Quinn founded a valuable organization called Crash Override that helps people deal with online harassment and abuse.

2. David Foster Wallace (1962-2008) wrote an extraordinary epic novel The Infinite Jest (1996) and his novel The Pale King was a finalist for the Pulitzer Prize. He hung himself after arranging some pages for his final novel. Wallace’s struggled with Major Depressive Disorder his entire life.

3. The definition and criteria for official psychiatric diagnosis remains the Diagnostic and Statistical Manual for Mental Disorders V written and published by the American Psychiatric Association.

Works Cited

Quinn, Zoë. Depression Quest. The Quinnspiracy, 2013. Interactive Fiction Game. Writer: Patrick Lindsay, Composer: Isaac Schanker.

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