Analysis of the Stigmatization of Mental Illness in Video Games Psychology Terrence J. Chambers III Thesis Advisor: Dr. Rebecca Regeth HAB Member: Dr. Justin Hackett Second Reader: Dr. Ryan Sittler Librarian: Loring Prest Keywords: mental, health, public, stigma, video games Abstract Video games often villainize mental illness as a means of explaining the behaviors of villains and other characters in the game (Shapiro & Rotter, 2016). Thus, the goal of this thesis is twofold: first, I analyzed a sample of 18 video games for their content concerning the stigmatization of mental illness. Second, I will then propose two alternative methods of presenting mental illness in video games: one method will be a suggestion aimed at the elimination of mental health stigma from video game content so that an alternative design to the current system is available. The second method is a suggestion aimed at educating players of video games on mental health in an effort to reduce mental health public stigma as a whole and improve knowledge about mental illness so that facts are more widely available than myth using Patrick Corrigan’s analyses on the different ways mental health public stigma can be confronted and reduc MENTAL HEALTH STIGMA IN VIDEO GAMES 1 Introduction The video game industry is an expansive network of technology companies and independent developers that provide entertainment to millions of individuals, with some estimates that as much as 97% of American children and adolescents play video games daily (Granic, Lobel & Engels, 2014). The amount of content in video games is massive and, at least in terms of plots and characters, contains as much variety as one might expect from libraries full of books from hundreds of different authors. Like books, games have intricate plots, dynamic heroes and villains, new fantasy worlds, dystopias, and portrayals of modern, past or future societies. Video games also portray mental health in a variety of ways, and, like other mediums that do this, can often inaccurately portray mental illness throughout the progress of the game (Shapiro & Rotter, 2016). This sometimes leads to the villainization of abnormal mental health in the games, and a sample of such games will be presented in this thesis. Like other forms of media, video games can frame how people think of particular aspects of society, including the perpetuation of stigma (Quintero Johnson & Miller, 2016). In this case, video games can affect people’s perceptions of mental health and lead to or confirm preexisting negative or inaccurate views of the audience’s perception of mental health. Video games portray mental health in multiple ways, from picking and choosing different symptoms of mental illness to being outlandishly false and inaccurate in its portrayal (Shapiro & Rotter, 2016). The characters that display these selected traits are often villains, antagonists or alienated characters of some kind, which leads to a false and villainizing portrayal of mental health to the audience playing or watching the game and this perpetuates the stigmatization of mental health in society (Goodwin & Tajjudin, MENTAL HEALTH STIGMA IN VIDEO GAMES 2016). This is an issue that has not changed over time, as this sample of games suggests by using games developed as far back as 28 years ago. A select few examples more accurately portray mental health, and these will be selected as examples moving in a positive direction for the portrayal of mental health in video games. When video games do portray mental illness, my analysis shows that it is often in a bad, inaccurate and villainizing or alienating light, and this can lead to negative perceptions or stigmatizations of mental health from the audience. 2 MENTAL HEALTH STIGMA IN VIDEO GAMES 3 Literature and Game Review The Games Grand Theft Auto V. Grand Theft Auto is a game series usually about conducting criminal activity to bring your main character(s) to power as a criminal underboss of some kind. The games rely a great deal on satire and often utilize it to make fun of certain aspects of society, such as society’s addiction to technology, or a satirical presentation of gun stores and gun culture. In this iteration of the series, the main characters are two former bank robbers, Michael and Trevor, and Franklin, a person trying to make enough money to live comfortably by almost any means. Each character has their own personality and history (Rockstar Games, 2013). Franklin comes from the city slums and has worked with gangs and as a repossession worker for a car dealer. Michael is a retired bank robber that is trying to live a comfortable life in the upper class part of town until his life gets derailed and he must go back to his criminal ways. Trevor is a former bank robber that lives out of town and is attempting to take over the crime businesses in the area through violence and killing. All three work together to pull of heists, build a criminal empire and live a wealthy life on top of violence and criminal behavior. The game is open-ended and gives the player their choice of missions to complete, as well as some limited decision-making in how the story will take place. Ultimately, there is a great deal of violence and the “heroes” of the story are criminals that get away with their crimes. While in previous installments, it was usually up to the player to go on civilian killing sprees, Trevor will do this on his own MENTAL HEALTH STIGMA IN VIDEO GAMES 4 sometimes when the player is playing as a different character at that time (Rockstar Games, 2013). The Sims 3. In The Sims 3, the player creates and controls the lives of “sims,” which are virtual people in a relatively open-world environment meant to fictitiously simulate someone living a regular life. There is no game-set goal as you play other than to help your sims live a fulfilled life or a miserable one. The player creates the sims themselves and can select their traits and goals in life. The goal is simply to play through a sim’s life with the ability to control up to 8 of them at a time in one household (Electronic Arts, 2009). Rimworld. Rimworld is a science-fiction sandbox survival game that places the player in control of people attempting to survive a crashed spaceship on an unknown and hostile planet. The goal of each playthrough is always the same: create and sustain a colony of people on the planet and attempt to escape the planet before a group large enough to destroy the player’s colony shows up and kills everyone. Each character, known as pawns, comes with a diverse set of backgrounds and traits that make every pawn unique and better or worse at particular skills (Ludeon Studios, 2013). League of Legends. League of Legends is a massively multiplayer online battle arena (MOBA), in which the player selects one of over a hundred champions to face off against others in a battle arena that pits five players against five other players with each in control of a champion of their own. The game boasts being the game with the most active players participating in the game in the world. Each champion in League of Legends has their own backstory, history and lore. This leads to interesting and diverse personalities for each of the champions, ranging from kind and benevolent leaders to violent and MENTAL HEALTH STIGMA IN VIDEO GAMES 5 destructive criminals with no care for authority and no regard for the lives of others (Riot Games, 2009). FarCry 3. In this game, players take on the role of Jason Brody, an American on vacation with his brother and friends on a tropical island that are captured by pirates and find themselves embroiled in a conflict for dominance between the pirates and the local population that leaves Jason’s brother dead at the hands of one of the game’s villains, Vaas Montenegro (Ubisoft, 2012). Resident Evil franchise. The Resident Evil series of games focus primarily on incidents of zombie outbreaks all over the modern world in the game universe. The games are generally survival-horror with some action games in more recent years. Full game synopses will not be necessary for each one, as most characters will be in multiple games with a few exceptions. Most of the games follow a similar arc for the conflict: There is an outbreak of some kind and the protagonists of each game must put a stop to it or escape with their lives. In most of the games, as well as the original cause of the first outbreak in the first game, the fictional pharmaceutical giant, Umbrella Inc., developed the biological weapons (often shortened to bioweapons) that created the horrors of the games in the first place. Resident Evil: Code: Veronica. In Code: Veronica, the player plays the game as two protagonists: Claire and Chris Redfield, siblings that are both veteran survivors of zombie outbreak incidents. In Claire’s mission to find her brother, she runs afoul of Umbrella and is imprisoned on an island used for the training of Umbrella’s private military. A zombie incident occurs here, and she must survive these horrors while also MENTAL HEALTH STIGMA IN VIDEO GAMES 6 facing off against the villain, Alfred Ashford and later his sister, Alexia Ashford (Capcom, 2000). Resident Evil 5. In one of the more actionized games in the franchise, players play as Chris Redfield and Sheva Alomar as the duo investigates reports of bioweapon experiments in Africa. Here they find evidence that Albert Wesker, the series villain and Chris’ rival, is attempting to release a biological weapon on a global scale that would kill most of humankind and leave him the ruler of what remained (Capcom, 2009). Resident Evil 7. This most recent installment of the series has players take on the role of Ethan, a regular person caught in an irregular situation, as he searches for his missing girlfriend in Louisiana. Ethan must survive a house of horrors while fighting off members of a family afflicted with a biological weapon that prevents them from dying (Capcom, 2017). The Evil Within. This game is a difficult one to describe. The player controls Sebastian Castellanos, a detective sent to investigate a report at a local asylum for mental illnesses. What he finds there are experiments being conducted on patients as well as a great deal of supernatural elements that make the player and the protagonist question their own sanity. The game is presented through the perspective of an unreliable narrator that may be suffering from audio and visual hallucinations. The villain, Ruvik, appears often and twists the player character’s reality on a whim, leaving them confused and disoriented often. All characters throughout the game suffer in different ways as the game progresses (Bethesda Softworks, 2015). Elder Scrolls IV: Oblivion. In this installment of the Elder Scrolls series by Bethesda Softworks, the player plays as a character known popularly as the Hero of MENTAL HEALTH STIGMA IN VIDEO GAMES 7 Kvatch. This name is selected as a general way of talking about the protagonist of this game by the players, as the player character him or herself is created entirely by the player: their race, their looks, how old they are, if they are male or female, and their traits are all selected by the player. The game is set up as an open-world role-playing-game, in which the player chooses the role of their character with a certain degree of freedom in their choice of abilities and actions they can take throughout the game. The story of the game is that you escape from imprisonment and vow to help fulfill the emperor’s last dying wish: to make sure his son ascends the throne and prevents the gates of Oblivion, a separate realm controlled by a powerful being known as a Daedra, from opening and destroying their world. Yet, as previously mentioned, the game is an open-world format with hundreds of other quests. There are many interesting characters to meet, and one very large expansion to the game to focuses entirely on insanity: the Shivering Isles DLC, in the realms of Madness (Bethesda Softworks, 2006). Elder Scrolls IV: Shivering Isles expansion. This game-sized expansion places the player character in the role of the champion of Sheogorath, the Prince of Madness, and deserves particular mention since its goal is very different from the base game from which the expansion comes. The goal of the expansion is for the player to succeed the Prince of Madness and stop the Greymarch, an event that leads to the destruction of the realms of Madness every era by the Prince of Order, Jyggalag. Again, the game has a focus on its open-world elements and side quests the player can undertake to explore and further understand the expansion and additional realm (Bethesda Softworks, 2006). Dragon Age II. In this installment in Bioware’s popular RPG series, the protagonist is Hawke, a person whose family is fleeing the Blight, an event in which MENTAL HEALTH STIGMA IN VIDEO GAMES 8 creatures known as Darkspawn attempt to destroy human civilization. The character creation itself follows a similar format to many open-world RPGs: The player decides the character’s looks, temperament, decisions in dialogue and combat style. Hawke and his/her family escapes the Darkspawn to the city of Kirkwall. This is where most of the game takes place with a branching main storyline that can have a couple of different outcomes based on player choice, although one thing always remains the same: A war is started between mages and their handlers, the Templars. The player must decide whether or not to side with Templars against mages or mages against Templars with a heavy emphasis on prior decision-making affecting how others feel about the protagonist and whether or not they will support him or her at this point. Throughout the course of the game, the player character meets characters of diverse backgrounds and races and can have many of them in his or her party as combatants and companions in their adventure (Bioware, 2011). Fallout franchise. There are a great number of Fallout games to discuss. All of the games in the series are open-world RPGs, in which the player character can go almost wherever they want at the start of the game. The player also creates the characters in each game: they decide the sex of the character, the character’s traits and perks, and their relevant skills from an extensive list of options ranging from combat skills to dialogue and stealth skills. In the later installments of the series, the player also decides what the character looks like. Each game takes place a certain time after 22 October, 2077, which marks the end of the Great War that destroyed modern civilization in a nuclear holocaust. Each game has its own story and goals for the player to complete with a focus on the open-world and freedom of choice elements present in many Bethesda RPGs. MENTAL HEALTH STIGMA IN VIDEO GAMES 9 Fallout 2. In the second game in the series, the player creates and plays the role of the Chosen One, a member of a primitive tribe on the verge of starvation in the year 2241, in norhern California. The goal of the story is to find the rumored Garden of Eden Creation Kit (GECK), which is said to have the ability to create an abundance of vegetation and life so that the tribe can survive. As the game continues, the player character’s tribe is targeted and destroyed by a militant group known as the Enclave, which is a group representing a twisted version of the United States government almost two hundred years after the collapse of all organized governments in a nuclear war. Like many open-world RPGs already mentioned, this game and others in the series have a diverse and extensive number of characters to meet and interact with throughout the course of the game (Interplay Entertainment, 1998). Fallout 3. In this installment, the player character creates and plays as the Lone Wanderer, a 19 year-old man or woman that is forced to leave the safety of their Vault, Vault 101, a shelter originally created before the nuclear war as a means of preserving human life on Earth, in order to find their father in a radiation-infested Washington D.C. 200 years after the bombs have fallen. Once again, the player character finds himself or herself in conflict with the Enclave and is sent on a path of revenge when the Enclave kills the player character’s father. The core story is focused on destroying the Enclave’s presence in Washington D.C. while also helping another group, the Brotherhood of Steel, finish a project to create radiation-free water for the citizens of the ruined city (Bethesda Softworks, 2008). Fallout: New Vegas. As the name suggests, this installment in the series takes place in the Mojave desert around Las Vegas, four years after the events of Fallout 3. The MENTAL HEALTH STIGMA IN VIDEO GAMES 10 player takes the role of the Courier, a character with an unknown and ambiguous past that is ambushed and left for dead due to an item the character is carrying at the beginning of the game. The core story of the game starts as a revenge story, but then focuses on a war for control of Hoover dam due to it being the largest producer of power in the entire region. There are four possible factions fighting for control of the dam: The New California Republic, a group known as Caesar's Legion, Mr. House’s faction and a possible independent faction with the Courier as the leader. Through player choice, the Courier can side with any of these factions and change the end of the game (Bethesda Softworks, 2010). Fallout 4. Taking place ten years after the events of Fallout 3, in the Commonwealth, a place in and around Boston, the player takes on the role of the Lone Survivor. The Lone Survivor is, as the name states, the only survivor of Vault 111, an experimental cryogenics facility. The player character was alive at the time the bombs fell in 2077, but has been cryogenically frozen until 2287 (Bethesda Softworks, 2014). The game features an open world and a core storyline originally focused on finding the character’s son and getting revenge for the murder of the player character’s spouse, but the story continues beyond this and becomes a war for control of the Commonwealth between four factions: The Brotherhood of Steel, the Railroad, the Institute and the Minutemen. Each faction stands for a different cause with their own beliefs and visions for the future of the commonwealth. Depression Quest. Depression Quest is a first-person text-based game focused on player choice. The player must make decisions to improve their condition throughout the MENTAL HEALTH STIGMA IN VIDEO GAMES 11 game and is intended to help people better understand depression (The Quinnspiracy, 2013). Hellblade. An upcoming game, Hellblade is going to be a fantasy action game about Senua, a girl whose tribe is murdered by marauding vikings. Many details about the game are currently unknown because it is still in development, but the team developing the game has released some details about the main character and that she is suffering from schizoaffective disorder (Ninja Theory, 2017). The Literature “Implicit Bias toward People with Mental Illness: A Systematic Literature Review.” Jayci Robb and Jeff Stone’s analysis of 19 different studies about the implicit and explicit attitudes towards people with mental illnesses focuses on answering the question, “Have there been significant studies focusing on implicit attitudes towards mental illness, and are there effective strategies to combat these attitudes?” What they found is that there needs to be greater research on this particular area, and that they have found no effective strategies in their search to combat this area of concern, as the current methods, personal contact and interventions, have been found to be insignificant in battling the implicit biases against people with mental illness (Robb & Stone, 2016). “The Benefits of Playing Video Games.” Among the arguments that video games promote violence and social isolation are some articles such as this that argue the benefit that video games can provide. Among these are numerous cognitive, motivational and social benefits that include interaction with new people and friends, effectively elevating one’s emotional state through the use of puzzle games, and greater problemsolving skills compared to many non-gamers. The authors of this article recognize the MENTAL HEALTH STIGMA IN VIDEO GAMES 12 potential harm that games can also do to a person’s self-esteem and levels of aggression, but insist that, like many other leisure activities in everyday life, video games have the potential for good as well as bad (Granic, Lobel & Engels, 2014). “Internalized Stigma of Mental Illness: Changes and Associations with Treatment Outcomes.” As the name suggests, this article discusses internalized stigma by people that suffer from mental illness. The article brings up a concerning point for treatment of people with mental illness: that internal stigma (their personal negative stereotypes associated with their mental illness) reduces the effectiveness of treatment and may even lead the person to avoid treatment altogether. The goal of this study was to analyze the effectiveness of short-term treatment plans in battling this internal stigma, and the authors found that these short-term plans showed a significant reduction in one’s internal stigma about mental illness, and that this reduction was associated with the person being more responsive to the treatment altogether (Pearl, Forgeard, Rifkin, Beard & Björgvinsson, 2017). “Perceived Primal Threat of Mental Illness and Recovery: The Mediating Role of Self-Stigma and Self-Empowerment.” This article pursued a connection between primal threat (the threat to one’s survival needs and feelings of belonging) and recovery from mental illness. Previous literature states that as the threat increases, recovery decreases and vice versa. The findings by this study were consistent with this view, and it was also found that participants’ degree of primal threat was also positively correlated with sense of self-stigma and their negative associations with their mental illness. The authors also noted that stressful stimuli could also activate primal threat in MENTAL HEALTH STIGMA IN VIDEO GAMES 13 regular individuals and decrease one’s opinion of their subjective health (Zhang, Mak & Chan, 2017). “Addressing Public Stigma and Disparities Among Persons with Mental Illness: The Role of Federal Policy.” As the title suggests, this article discusses the role of federal policy in the perpetuation of public stigma towards mental illness, as well as how federal policy has attempted to correct this issue. It mentions that while protections are in place for members of this group, these protections are not uniform and do not protect certain subgroups. It also discusses the effectiveness of federal policy in regulating personal stigma towards mental illness, which is minimal. It concludes that the current system is inadequate in providing protection for the population of those suffering from mental illness, and that a comprehensive system of education, contact and federal regulations aimed at reducing stigma will be much more effective in reducing people’s personal stigma towards mental illness (Cummings, Lucas & Druss, 2013). “Primary Care, Behavioral Health, and Public Health: Partners in Reducing Mental Health Stigma.” This article discusses reforms that could help with the reduction of mental health stigma as well as identifying possible concerns earlier than the current system allows by integrating mental and behavioral health into primary care. This integrated approach could help in reducing stigma for seeking aid as well as possibly screen for major mental or behavioral health concerns in patients to a primary care provider. However, the article also informs that the process is expensive and time consuming, and that the current model of primary care cannot support this integration (Shim & Rust, 2013). MENTAL HEALTH STIGMA IN VIDEO GAMES 14 “Resolving Mental Illness Stigma: Should We Seek Normalcy or Solidarity?” Patrick Corrigan’s article discusses two strategies for combating the stigma surrounding mental illness: normalcy, the strategy of downplaying the difference between individuals suffering from mental illness, and solidarity, the strategy of celebrating the differences and standing by those people that are different regardless of that difference so as to help them and provide them with the support and understanding necessary to aid them. The second strategy is similar to the common stance for homosexuality in the western world and has proven to be highly effective in this case (Corrigan, 2016). “Erasing the Stigma: Where Science Meets Advocacy.” Corrigan and Kosyluk identify multiple vehicles and processes necessary for confronting public stigma towards mental illness, as well as the risks and benefits of using each one. The authors’ goal was to inform the reader that not all strategies for reducing public stigma are effective at all times, and some may even harm the intended outcome (Corrigan & Kosyluk, 2013). “When Women ‘Snap’: The Use of Mental Illness to Contextualize Women’s Acts of Violence in Contemporary Popular Media.” This article discusses the use of mental illness by different media as a means of explaining behavior. It does this by using examples from film and news media and criticizes the media in perpetuating stigma towards mental illness in its coverage of this particular subject (Quintero Johnson & Miller, 2016). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition: DSM-5. The DSM-5, published by the American Psychiatric Association, contains details for all of the current accepted mental health disorders recognized by that association through an extensive research and vetting process. It includes symptoms, necessary conditions, MENTAL HEALTH STIGMA IN VIDEO GAMES 15 background and statistics about each of these disorders and will be used extensively throughout this thesis when discussing characters and conditions from the games (American Psychiatric Association, 2013). Mental Health Stigma in the United States As mentioned in various sources included in this thesis, there is a general public stigma concerning mental health in the United States and elsewhere (Cummings, Lucas & Druss, 2013). The public stigma towards mental health includes common beliefs that those suffering from mental disorders are dangerous and should be avoided, and that people with mental disorders are uncontrollable and violent. Of course, the stigma changes slightly depending on the disorder, but the general public opinion is that people suffering from many of the mental disorders to be discussed are dangerous individuals with little to no self-control (Cummings, Lucas & Druss, 2013). The stigma is so widespread in the United States that legislation has been necessary to reduce the discrimination related to it. Cummings, Lucas & Druss (2013) discuss three pieces of legislation passed recently that attempted to reduce this stigma: The Mental Health Parity and Addiction Equity Act of 2008, the Patient Protection and Affordable Care Act of 2010, and Individuals with Disabilities in Education Act. All three pieces of legislation were aimed at reducing discrimination associated with mental health stigma, but as the authors point out, these protections are not uniform, and these laws simply do not change people’s attitudes concerning mental illness. These laws are made even more ineffective when local and state legislation appears to run counter to federal legislation by imposing restrictions on people with mental illness. Wolf and Rosen (2015) discuss state and local legal responses to many of MENTAL HEALTH STIGMA IN VIDEO GAMES 16 these violent tragedies in their article. Legislation after events like the Newtown school shooting specifically target people diagnosed with a mental disorder and prevent them from purchasing certain firearms when most violent crimes are not perpetrated by this population of individuals. The authors write, “The truth is that individuals falling into the category of ‘mentally ill’ only account for a small fraction of all violent conduct. Simply having a mental illness is not a strong predictor of future violence” (Wolf and Rosen, 2015, p. 853). The authors also say that, “people assume those with mental illnesses are more prone to violence than those without these issues” (Wolf and Rosen, 2015, p. 853). Yet with the news coverage these events get mixed with where news outlets place the blame, the stigma persists through attempts to help eliminate or lessen its effects. Even when this stigma is not openly presented, studies show that implicit bias remains. Robb and Stone (2016) found that while a great amount of research has been conducted on eliminating explicit (externalized) bias against mental illness, less has been conducted on implicit bias. The authors also say that current methods “do not significantly improve implicit attitudes” (Robb & Stone, 2016, p. 10), meaning the current methods used by researchers and professionals to reduce overall stigma towards mental health and mental illness are ineffective at improving internal attitudes and beliefs in this subject. Effects of Mental Health Stigma This stigma does harms on many fronts. First, it affects the attitude of the general public towards those that suffer from mental illness. People become avoidant of people with mental health problems, treat them differently ranging from being openly hostile to pitying and tend to fear them. With public stigma also comes internalizing stigma for MENTAL HEALTH STIGMA IN VIDEO GAMES 17 people with mental illnesses. When a person with a mental disorder agrees with and accepts the public stigma towards mental illness, they internalize these attitudes and feel similarly about themselves. Zhang, Mak and Chan (2017) write that self-stigma/ internalized stigma damages the recovery process of someone with a mental illness, and may cause primal threat, which is a perceived threat to one’s well-being and belonging in the world. The authors say that the recovery process is made extremely difficult or impossible with the presence of self-stigma, as the people take on an attitude of helplessness and may even make the situation worse. Shim and Rust (2013) write that public stigma surrounding mental illness also prevents those suffering from behavioral health problems and substance abuse from seeking help for fear of being stigmatized and treated differently by peers and colleagues. Clearly, the perpetuation of this negative stigma towards mental illness has far-reaching negative effects that can make a bad situation much worse. How Video Games Perpetuate Mental Health Stigma With these effects in mind, it becomes clear that many video games perpetuate this stigma. This is done in multiple ways. As discussed in this thesis, there are a number of examples in video games where mental illness is used as a way to explain a villain’s actions. There are also games that use mental illness as “set dressing,” in which the setting and most of the people involved are affected in some way. Other games use mental illness as a way for the player and characters to feel bad for those that appear to be suffering under their conditions, yet this is still a perpetuation of a different kind of stigma that results in pity rather than empathy for the individual. Very few games MENTAL HEALTH STIGMA IN VIDEO GAMES 18 recognize the stigma being perpetuated in some way and attempt to do something to combat it. Analysis of Mental Health Stigma in Video Games All but two of the games selected for this analysis are or were commercially successful and are widely popular in at least the United States, as this is an analysis concerning the stigma in the United States and not elsewhere. Characters will be analyzed according to the DSM-5 criteria and then discussed in terms of the stigma of mental health. It is important to note that for most characters present in the following games, the player is given only a brief snapshot of that character’s life. Many diagnoses would require a great deal more information than what is present in the games. However, this does not make the analysis and discussion of stigma any less important: Game developers design these characters in such a way as to get the response from the player that “The villain from X game is just crazy,” which leads to the perpetuation of mental health stigma. Organization of this section will be based upon the disorders reflected in the games rather than game-by-game. Schizophrenia Spectrum Disorders Schizophrenia spectrum and other psychotic disorders are characterized by abnormalities in one or more of five domains: “delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia) and negative symptoms” (American Psychiatric Association, 2013, p. 87). Schizophrenia and associated disorders are complex and heavily researched disorders that are commonly utilized in video games for villains or alienated persons in society. MENTAL HEALTH STIGMA IN VIDEO GAMES 19 Fallout 3. Psychotic symptoms associated with Schizophrenia and its related disorders are ever-present in the post-apocalyptic game series. This can be related to the fact that almost all individuals in the games have suffered from constant radiation exposure throughout their lives, but the actions undertaken by some of these individuals still perpetuate the stigma that people suffering from this spectrum of disorders are dangerous and need to be avoided. This is particularly evident in Fallout 3. The player character can encounter an individual that speaks with lines that make no sense: “Hungry… hungry… so hungry. What? No. I’m not hungry. The worm is hungry. Hungry for me, for you, and for fire” (Bethesda Softworks, 2008). He goes on to say, “Trees! So many trees! To the north! But be careful… the trees… are deadly, and the trees too will be consumed in the belly of the great fat worm!” (Bethesda Softworks, 2008) as well as “The sun will rise in the north! No! The northwest! For forty-four days and sixty-seven nights!” (Bethesda Softworks, 2008). His speech is clearly disorganized, and he may also be hallucinating. Because of how brief the encounter is, the closest DSM-5 disorder to his actions is brief psychotic disorder, but this is the furthest the analysis can go concerning the mental health of the individual, as the player character is not able to find out if the person has been taking any substances to cause this psychotic episode. If the player character approaches him, he will kill himself and the player character with explosives, indicating that people with these symptoms are violent and unpredictable, when in reality these individuals are only more likely to commit suicide than harm others (American Psychiatric Association, 2013). MENTAL HEALTH STIGMA IN VIDEO GAMES 20 Dragon Age II. In Dragon Age II, the player character and his/her party are sent to find and capture a criminal by the name of Kelder, who preys on elven girls and kills them. When you finally meet Kelder, he says, “She [The elf girl] had no right to be so perfect, so beautiful. The demons said that she had to be taught a lesson” (Bioware, 2011). Demons are a very real threat to the mind in the series, which would eliminate any questions of a schizophrenia spectrum disorder. But if a mage is in the party, it will be revealed that there are no demons plaguing Kelder. Once again, a man suffering from hallucinations is presented as violent and unpredictable, and the player character is given the option of killing Kelder or handing him over to authorities. If he is handed over to the authorities, it is later revealed that he “was mad” (Bioware, 2011). The Evil Within. Perhaps the game in this analysis that perpetuates mental illness stigma the most, The Evil Within uses symptoms of schizophrenia spectrum disorders to make the entire game. This is a common theme for horror games. The player character and many others in the game suffer from auditory and visual hallucinations throughout the course of the entire game, leading one character to take violent action against a close friend. Leslie, a character that comes from an asylum for the mentally ill, speaks incoherently for much of the game and has frequent episodes of disorganized behavior. Due to his long-term stay at a mental hospital, it can be assumed that these features are longstanding for Leslie (Bethesda Softworks, 2014). Leslie is an enigma to the main character and the player of the game for much of the story, and he is set apart from other characters as odd or disturbing. The perpetuation of stigma towards schizophrenia is a particularly major issue. As a category of mental disorders with clearly visible symptoms, these individuals are easily MENTAL HEALTH STIGMA IN VIDEO GAMES 21 noticed and public stigma is a major concern. People with this category of mental disorder often become socially withdrawn and suffer from feelings of helplessness and depression (American Psychiatric Association, 2013). Paranoid Personality Disorder In short terms, paranoid personality disorder is “a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent” (American Psychiatric Association, 2013, p. 645). Oftentimes, characters that display paranoid personality disorder in video games are alienated or presented as odd or quirky to the player. Grand Theft Auto V. Multiple characters display this. Lester, an acquaintance of the main characters of the game, is excessively secretive and constantly suspicious of others. He shuts himself in his home and rarely leaves, and believes that others only intend him harm. People with paranoid personality disorder also tend to hold extreme grudges for insults and slights (American Psychiatric Association, 2013), and some of the missions the player can do for Lester include killing people who appear to have done this to him in some way. In many ways, Trevor displays this as well. He believes that the government is always out to get him and others, and trusts very few people (Rockstar Games, 2013). The Elder Scrolls IV: Oblivion. In the Shivering Isles, the duchess of Dementia, Syl, displays long-term paranoia and suspects that everyone around her wants to kill her and take her throne. She orders the player character on a chase to uncover a loose plot and kill those involved (Bethesda Softworks, 2006). Of course, while Syl is always this MENTAL HEALTH STIGMA IN VIDEO GAMES 22 paranoid, it is worth noting that there was indeed a plot to kill her and that, in this one case, her paranoia was accurate. Dragon Age II. Anders, a member of the main character’s party, also displays this with a much greater timeline. The in-game codex entry about Anders can say, “The past three years has seen Anders cross the edge from moodiness to open paranoia” (Bioware, 2011). Anders, a mage devoted to freeing mages from Templars, becomes extremely paranoid that people may be trying to kill him or inform on him to the Templars. These examples stigmatize people suffering from paranoid personality disorder as crazy shut-ins that will kill anyone they think would bring them harm or slight them in some way. Not only do these examples harm public opinion of individuals with this disorder; it can also reinforce the beliefs a person with this disorder may have about others. Antisocial Personality Disorder According to the DSM-5, a person with antisocial personality disorder must display a “pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years” (American Psychiatric Association, 2013, p. 659). They must be at least 18 years old, have evidence of conduct disorder in their childhood, and the behavior must not occur exclusively during the course of schizophrenia or bipolar disorder. The person in question must also display at least three of the following traits: “failure to conform to social norms in respect to lawful behaviors… deceitfulness… impulsivity… irritability and aggressiveness… reckless disregard for safety of self or others… consistent irresponsibility… [or] lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another” (American MENTAL HEALTH STIGMA IN VIDEO GAMES 23 Psychiatric Association, 2013, p. 659). Often, when someone thinks of what a psychopath or sociopath is like, this is the disorder closest to those thoughts. FarCry 3. Vaas Montenegro is a textbook example of antisocial personality disorder. He has no regard for human life and kills the main character’s brother in front of him. He is impulsive, easily irritated and is a pirate that traffics drugs and people (Ubisoft, 2012). Resident Evil franchise. Multiple villains in the entire franchise display this. Alfred Ashford, from Resident Evil: Code: Veronica cares little for ethics, experiments on members of his own family with deadly viruses, and houses prisoners for the sole purpose of torturing them (Capcom, 2000). Albert Wesker, the main villain of the series, displays this particularly well in Resident Evil 5 when he rationalizes infecting the entire world with a virus that will transform individuals into better beings while also killing any who are too weak (Capcom, 2009). Lucas Baker, in Resident Evil 7, enjoys setting up traps for people to kill them, is easily irritated, feels no remorse for his actions, and constantly lies to the player character. Through notes found throughout the game, it becomes evident that he has been doing this to people since he was a child (Capcom, 2017). League of Legends. There are multiple examples in one of the most popular multiplayer games in the world. Jhin is a champion whose backstory informs the reader that he rationalizes his killing as an artwork. He hates when things are not perfect in his own way, and becomes easily irritated and aggressive when he is interrupted during his “work.” Jinx is a criminal with no regard for authority or the safety of herself or others. MENTAL HEALTH STIGMA IN VIDEO GAMES 24 She is impulsive and violent, with her most notable line being, “Rules were made to be broken. Like buildings. Or people” (Riot Games, 2009). Rimworld. Players may find their colonies of pawns with many different traits that define the personalities of the colonists. One such trait is called “psychopath.” The trait description says that the individual feels nothing when prisoners are killed or sold into slavery, and their mood is unaffected by witnessing the deaths of others. They also get no mood change when speaking to other people. “Normal” pawns are all affected by these events, but pawns with the psychopath trait are not (Ludeon Studios, 2012). The Evil Within. Ruvik, the villain of the game, has no regard for authority or the lives of others. As a researcher at a mental hospital, he unethically experiments on patients like Leslie, with his rationale as, “These vermin? These microbes? They’re mine to do with as I please” (Bethesda Softworks, 2014). It is also revealed that Ruvik murders his father, and he is described by another character as “a serial killer masquerading around as a scientist” (Bethesda Softworks, 2014). Fallout franchise. The Fallout series is full of examples of multiple disorders. In terms of antisocial personality disorder, there are examples from multiple games. In Fallout 2, Frank Horrigan appears to have this. Although a mutated human exposed to radiation like everyone else, Horrigan believes himself superior and rationalizes his killing of others as their being inferior and mutated. He is impulsive, angers easily, and cares little for the lives of others or even himself in combat (Interplay Entertainment, 1998). In Fallout: New Vegas, the faction known as the Fiends embody this as a theme. Their leader rationalizes that if they can take it from someone else, then it is theirs by right. Their leader, and the faction as a whole, has no regard for the authority of the only MENTAL HEALTH STIGMA IN VIDEO GAMES 25 organized government in the area, the New California Republic, and all are impulsive and irresponsible, including intense drug and alcohol abuse (Bethesda Softworks, 2010). In Fallout 4, the player character can meet Pickman, a man who kills raiders without remorse. Like Jhin from League of Legends, Pickman creates art from his victims. He has a disregard for his own safety in his mission. His actions are usually forgiven by the player character, as Pickman only targets raiders, which prey on others (Bethesda Softworks, 2015). Grand Theft Auto V. Trevor appears to have elements of antisocial personality disorder. Trevor clearly has no regard for the well-being of others. He is extremely impulsive, very irritable and aggressive, and cares little for social norms. The player can change to his perspective during gameplay and sometimes find him killing police officers in a gunfight or drunk and naked in the middle of the desert (Rockstar Games, 2013). Antisocial personality disorder, or just villainous? Antisocial personality disorder traits are commonly used in video games as a means of defining a villainous character. People may argue that this is coincidence: Many of the traits associated with antisocial personality disorder are also traits people associate with villains: lack of remorse, aggressiveness, reckless disregard for safety of others and a disrespect for authority are all things “bad” people might do. The concern for stigma here is not necessarily in the alike traits of the villains and the disorder, but in the delivery of the character. Oftentimes, these characters are presented as being like this without much background or justification. They are simply this way because that is who they are. If someone were to ask a player of Grand Theft Auto V why Trevor acted the way he did, they might just say “that’s because he’s crazy.” This is what perpetuates the stigma in MENTAL HEALTH STIGMA IN VIDEO GAMES 26 question. The label of “crazy” or “insane” is applied to many disorders, and thus the stigma that people suffering from mental illness are dangerous and unpredictable is perpetuated further. In the uninformed mind, there may not be a distinction between Trevor’s “crazy” and Leslie’s “crazy” even though one is violent and the other is not. So, while some of these traits may overlap with what society considers to be villainous, the delivery of the characters by the designers results in furthering this stigma. Bipolar I Disorder In shortened terms, all that is needed for bipolar I disorder is one manic episode in which one’s mood is extremely, abnormally and persistently elevated for at least one week, with symptoms of grandiosity, decreased need for sleep, racing thoughts, extreme talkativeness, distractibility or excessive involvement in risk-taking activities are noted with the severity causing impairment in daily life (American Psychiatric Association, 2013). Characters that show these symptoms are usually portrayed as irrational, aggressive risk takers. Grand Theft Auto V. As Michael speaks with his psychiatrist, he reveals that he may sometimes fit in this category: “One moment I’m calm, the next I’m crazy” (Rockstar Games, 2013). Trevor may also suffer from manic episodes during his rampages, as he becomes extremely talkative, feels (and is) nearly invincible, and engages in violent risk-taking behaviors. Elder Scrolls IV: Oblivion. Sheogorath is the embodiment of this disorder. He is the Prince of Madness, and his speech indicates that his thoughts change quickly when he says “Now get going. Before I change my mind. Or my mind changes me” (Bethesda Softworks, 2006). In Sheogorath’s realm, one of the provinces is known as Mania, and MENTAL HEALTH STIGMA IN VIDEO GAMES 27 the people here are meant to embody this idea of risk-taking and irrationality (Bethesda Softworks, 2006). The Sims 3.Within the Sims 3 is a trait called “insane.” This trait makes Sims act in irrational ways, wear and do bizarre things like rummaging through trash or acting like an animal, and act as a nuisance or joke to other Sims. While clearly intended as a joke and bit of fun to make the player’s Sims act oddly, it is an insult to people who must cope with their mental illness (Electronic Arts, 2009). Once again, video games stigmatize traits of a mental disorder and harm the image of those actually dealing with these illnesses. These games paint people with these traits as violent, impulsive and disorganized. Yet the reality is that individuals with Bipolar I tend to commit self-harm instead, and may account for up to “one-quarter of all completed suicides” (American Psychiatric Association, 2013, p. 131). Are Video Games a Nuisance to Society that Perpetuate Negative Stereotypes? Absolutely not. While a number of video games perpetuate stigma associated with mental illness and drug abuse, there are benefits to playing video games. Even violent games like Grand Theft Auto V (2013) have shown benefits for those that play them, including benefits to attention allocation, visual processing and mental rotation abilities (Granic, Lobel & Engels, 2013). Data shows that these skill improvements may even be comparable to formal courses aimed at improving the same or similar skills (as cited in Granic, Lobel & Engels 2013). In the same article, the authors provide evidence that video games benefit players by improving social interaction (in multiplayer games such as World of Warcraft), motivation through engagement with games, and reduction in anxiety and stress through games with short-term investments like Bejeweled (Granic, MENTAL HEALTH STIGMA IN VIDEO GAMES 28 Lobel & Engels). Regardless of the intentional or unintentional perpetuation of stigma and negative stereotypes surrounding mental illness, video games are beneficial. The concern is therefore not “what should we do about games?” but “what should games do about mental health stigma?” Rather than perpetuate these ideas, video games can take alternative paths. Recommendations for Eliminating Stigma in Video Games Below are my recommendations for helping prevent the perpetuation of mental health stigma in video games. There has been a great deal of research on mental health stigma and how to help eliminate public stigma through multiple techniques proposed by Patrick Corrigan and others. Corrigan and Kosyluk (2013) outline the different ways people can confront mental illness stigma and attempt to change public opinion on the subject, and it will be the basis for my recommendations for eliminating mental illness stigma. Eliminating and Combating Stigma in Video Games A great deal of the stigma from the video games mentioned throughout this analysis is present because of shallow character design. Many of the characters mentioned are not given backstories, or the rationale in the backstory only confirms the already-existing idea that the character in question is somehow insane. If a designer can get the idea to the player that a character is crazy, violent and needs to be stopped, then further explanation for the character’s actions is unnecessary. Then, the player can simply get to the “good” parts of games, like fighting and exploring rather than thinking about why a villain may want to destroy the world. A simple fix to this in future games would be to provide a greater focus on character development. An example is Hellblade: MENTAL HEALTH STIGMA IN VIDEO GAMES 29 Senua’s Sacrifice. Senua suffers from schizoaffective disorder after losing her family and friends to a viking raid. Like schizophrenia, schizoaffective disorder includes delusions or hallucinations as well as a manic or major depressive episode (American Psychiatric Association, 2013). The team provides basis for the disorder in the character’s backstory, but stigma may still be a concern due to the violent nature of the game (Ninja Theory, 2017). However, this is still a step forward that the game industry could use to set a precedent for handling characters with mental illness: greater character development and rationale for character actions may lead less to blaming some nameless insanity for the character’s inherent fault, and instead lead to the identification of the context surrounding the character’s actions. Alternatively, game designers can change how characters with mental illness are presented in their games. Corrigan (2016) outlines two ways in which this can be done in society, and I have applied it to video games here. Two ways to approach eliminating mental illness stigma are through normalcy and solidarity. In the normalcy view, differences are reframed to be less striking and facts are used to counter myths. Corrigan writes that the strategy works well in the beyondblue campaign in Australia, and that it allows the people there to better recognize the illnesses and understand the benefits of treatment (2016). This is actually utilized in one game I was able to find: Depression Quest. This text-based game allows players to identify actions that will benefit a person suffering from depression and also help them recognize the illness in a person. It educates the player while also helping increase understanding and reduce stigma surrounding the illness (The Quinnspiracy, 2013). MENTAL HEALTH STIGMA IN VIDEO GAMES 30 Corrigan (2016) also discusses another approach: solidarity. In this approach, the difference is celebrated in a word. Promoting solidarity means standing by these individuals regardless of their mental illness and supporting them through hard times. Similar to supporting someone for “coming out” as a member of the LGBTQ community, it is understanding them and being there for them even though they are different. Identity with peers and social groups allows persons with mental disorders to experience less harm to self-esteem and recovery by internalized stigma (Corrigan, 2016). Video game developers can utilize this technique in a number of ways by designing a character with a mental illness and providing the player character the ability to support and aid that person in some way and allow the player to see that person improve in terms of their self-esteem and personal abilities. A representative example of this method can, again, be found in Depression Quest. The player character must make choices throughout the game to improve the life of a person suffering from depression, which provides an interactive platform in which that player sees a distinct improvement in the character’s mental wellbeing (The Quinnspiracy, 2013). In another study, Corrigan and Kosyluk (2013) contrast various strategies commonly used in erasing public mental illness stigma. The three processes are protest, education and contact, with two vehicles of transmitting these processes: media and in person. The original research with these vehicles and processes was originally conducted to reduce intergroup prejudice with in-person contact being the most effective strategy for effectively reducing prejudice and, later, mental illness stigma. The process of contact can also be utilized in gaming. Corrigan and Kosyluk (2013) say that in-person contact has the most impact, and this is not possible with video games as the medium. Yet video MENTAL HEALTH STIGMA IN VIDEO GAMES 31 games have the potential to be effective in erasing stigma through the interactiveness of the game itself. To return to a different article, “Game designers are wizards of engagement” (Granic, Lobel & Engels, 2013, p. 70). Because of the engaging and interactive nature of video games, the games themselves have the potential to be an effective medium at contact with mental illness to dispel myth and reduce public stigma. Conclusion Video games have the capacity to perpetuate mental health stigma or confirm preexisting negative stereotypes about persons with mental disorders. As evidenced in my analysis, many popular video games utilize mental illness as a tool for defining villains or alienating characters throughout the game. This leads to a perpetuation of an already serious public stigma that harms the image of people with mental disorders and may even prevent them from trying to seek help for their disorder, or harm their ability to cope or recover from a mental illness. Yet video games also have the capacity to turn this around. With a change in game design, games can help reframe public opinion concerning mental illness and help people realize that the difference between a person with a mental disorder and someone without is less striking than one might think. With a change in character design, a villain may not be defined by how crazy or insane they seem, and may even help people dig deeper when it comes to what motivates a person’s actions. Video games even have the potential to help reduce public stigma by educating those that play the games on these disorders without villainizing them, and also provided a virtual and interactive contact zone in which players can better come to an understanding and empathize with persons suffering from mental illnesses. As the video game industry currently stands, it is MENTAL HEALTH STIGMA IN VIDEO GAMES 32 perpetuating a negative view of people with mental illnesses and only adding fuel to the fire that is mental health public stigma. However, this stance, intentional or unintentional, can be changed. 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