There’s nothing to be worried about, it’s just a quiet walk through the woods. The sun is shining through the leaves. Strings swell in the background as you amble about. Everything is okay.
Only it isn’t. Sure, Alessandro Salvati’s Anxiety Attacks starts out pleasantly enough. You are in the woods and everything is indeed picturesque. Your only real job is to breathe. Breathe in. Breathe out. Walk through a field of flowers. Breathe in. Breathe out. Breathe—you get the hang of it. Well, you think you’ve got the hang of it, and then the sky turns red, your breath shortens, vines claw at your field of vision like a possessed creature’s tentacles, and your screen is flooded with messages about your inadequacy. You are experiencing an anxiety attack.
Much as there are many ways to experience anxiety, there are many ways to experience Anxiety Attacks, very few of which will leave you in a peaceful state of mind. The most intriguing option is to watch the small collection of Let’s Play videos on YouTube, which juxtapose the formal conventions of the genre with the experience of what Salvati describes as a condition affecting “15% of the entire world population.” (The exact share of the population suffering from anxiety disorders is contested, but Salvati’s figure is in the same range as other surveys.) This approach to the game is probably not the best way to appreciate Salvati’s artistry, but it succeeds in raising its own questions about games and human behaviour. Namely: faced with an experience that many humans face, how will our stoic videogame narrator react?
“Ooh,” says YouTuber Philofhatsandgames as the game’s first anxiety attack strikes. His face, which occupies the top-right corner of the screen, remains impassive. The sound of breathing becomes more pronounced—not Phil’s breathing, mind you, but that of the game’s protagonist. Alarming messages fly into the foreground: “I’m weak; I need help; I’m paralyzed; I’m powerless; Alone; I’m stuck.” Phil spins around, but the dark thoughts are coming from every direction. “It’s okay. It’s okay,” Phil says in an even tone. He goes silent for thirty seconds, long enough to notice the interval and start counting his blinks. His voice eventually returns, like Apollo 13 rounding the moon and coming back into contact. “Yikes!”
Phil gradually gets a handle on the game. As he does, his face loses its affectless quality. “That’s right, you’ll be okay,” he enthusiastically pronounces. Who is “you” in that sentence? Who is he trying to convince? Phil escapes his first anxiety attack and pronounces, “This game is not for the faint of heart, but I’m fascinated by it.” He’s less than eight minutes into his 26-minute video.
To watch Phil work his way through Anxiety Attacks is to reckon with the extent to which games can serve as therapy. “That’s right buddy, you can do it,” he tells the screen. This is both an encouraging and somewhat therapeutic thought. It sounds like something he might tell his avatar in any other scenario. The game is either affecting how he thinks about mental health or simply recontextualizing linguistic tics already associated with games. Either way, games and their associated media provide a forum for working through these issues in public.
It’s better to have Phil work out these issues than deal with them yourself. If he can do it, maybe there’s some hope for the rest of us. “That was Anxiety Attacks, guys. It’s not a good thing to have those especially when they’re severe,” Phil concludes. True. Before signing off, he adds: “Take someone with you when you go on walks.” He’s on to something there: We may all need a bit of help navigating life’s literal and figurative forests.
I can’t tell you when I first lost sight of the forest for the trees. Maybe it was as a high school student, where the highs of travelling for competitions were usually followed by crushing lows. I’d occasionally scrawl notes to that effect and forget where I left them. The discovery of such notes occasioned all manner of awkward questions about what they meant, questions that I was never in a position to answer. I was a teenager—a subsection of humanity known for its lack of self-awareness and emotional fluctuations—who liked dark music. Maybe I was sad. Maybe I was parroting my cultural consumption. Maybe I was self-indulgent. I, of all people, couldn’t solve this riddle, which led to many variants on the following conversation:
“Are you okay?”
— “Of course I’m okay. Why are you even asking?”
I’m not okay.
Most days, I’m good enough. It just takes a lot of work. I’m exhausted. The minimum threshold for making it through the day is attainable, but I spend a lot of time thinking about. Its existence is more of a challenge than a comfort.
It’s hard to quantify the effect of living with anxiety and periodic bouts of depression. The occasional metric presents itself: The historic trends monitored by my phone’s pedometer serve as a diary of all the times I told myself I’d walk around the block to calm myself down before doing something. One lap becomes two becomes 10,000 steps before 10:00am. That’s as concrete as it gets. Everything else—the days spent without leaving unlit bedrooms, the menial tasks turned into crises, the emotional labour inflicted upon others, the trouble eating, randomly crying on the bus—is squishy.
If that all sounds like nonsense, I don’t really disagree. Most discussions of the symptoms of depression and anxiety tend to devolve into truisms: depression means sadness; anxiety means stress. These explanations have the benefit of sounding concrete. Tell someone you’re sad and they’ll know what you mean, or at least claim to know. But such truths are trivial. Everyone gets sad and stressed; the real problem is not knowing what to make of these emotions.
Anxiety and depression are, above all else, attacks on your brain’s ability to contextualize feelings and information. What’s the difference between a bad day and my world collapsing? Will I always feel this way? Will things ever get better? Is there something wrong with me? Does everyone feel like this? I can’t answer any of these questions. The difference between a momentary bout of sadness or anxiety and a prolonged crisis is, in large part, believing that the precipitating event is normal and that these things usually pass. Without that faith, or any understanding of what constitutes a minor setback, all feelings become weaponized. They fold in on one another, creating new and compounding crises until all points of reference are lost.
This inability to contextualize feelings also makes it hard to contextualize actions. How am I to know if my bouts of laziness or inability to focus are products of my anxiety or a natural state of being. The same goes with my tendency to lash out at friends or abruptly cut off correspondence. I reckon with these questions on a daily basis, and spend even more time on this one: Why am I such an asshole? On the one hand, anxiety is a part of who I am. It will not be excised anytime soon. It is a part of who I’ll always be. Thus, to say it’s the anxiety acting is to let myself off the hook. There is no doer behind the deed. At the same time, I’d rather not be defined by my ailments. Anxiety is not all that I am, though it can definitely feel like it. I’d like to think that there is some separate part of me that remains untainted. So, to the extent that there is such a thing, which one is my ‘real’ self?
One of the promises of interactive experiences, as extolled in both specialist texts and the general press, is that they offer a low-stakes venue for trying on different selves and new identities. You may be a nervous wreck of a white man offline, but you are under no obligation to be any of those things online. As the developer Jake Elliott puts it, videogames allow you “to explore a simulated space with no consequences. You can try on different behaviors, see the outcomes, and learn how you feel about it.” Players often take advantage of this freedom. A significant percentage of cisgendered male gamers, for instance, sometimes play as women in MMORPGs. Trying on different identities can be a way for players to distance themselves from their ‘real’ selves or to find such a thing through experimentation. The choice is theoretically theirs.
But online spaces only offer so much latitude. Even if they are under no obligation to do so, players often bring elements of their offline selves into games. “Even when we believe we are free and empowered, our offline politics and cognitive baggage prevent us from changing,” writes Ubisoft’s Nick Yee. Psychological studies, for instance, that all sorts of racial biases affect player relationships with their avatars. Many players badly want to leave their real lives behind, but it can still follow them into games.
This tension between the potential freedom afforded by games and the baggage that cannot be outrun is especially pronounced in games about anxiety and depression. How do you try on new identities when an emotional condition tinges everything? Is anxiety one of the things players leave behind or a part of real life that bleeds into games? These questions also apply to game creators and distributors. In the absence of concrete knowledge about the sort of promises that can honestly be made, the language used to describe games about anxiety is maddeningly imprecise. That’s how you get PR emails with subject lines like this one, which I received in September: “Can Video Games Help You Manage Stress & Anxiety?” Good question.
This question of how much games can really accomplish dovetails neatly—perhaps too much so—with talk of new technologies as tools for generating empathy. Games may or may not be able to help with anxiety, but can they help others understand what it’s like to live with such difficulties? This, in short, is the promise of virtual reality: by taking on different identities, you can better empathize with the experiences of others. In his popular TED Talk about VR, Chris Milk talks about immersion as a means of creating deeper and more meaningful empathy for others. TED calls the talk “inspiring.”
The talk may be inspiring, but how much understanding can an interactive experience—five minutes in a headset or a few hours in a game—inspire? Some knowledge is probably better than nothing, but it’s not yet clear how much better. Moreover, there is a considerable danger of overestimating the amount of information that can be gleaned from an interactive experience. This sort of faulty calculus turns empathy into erasure. Mitu Khandaker coined the perfect term for these faulty expectations of technology: “Magical Empathy Machines.”
There is no magic here. Understanding takes time and effort. Technology may expedite matters, but it is not a remarkable shortcut. This leaves everyone in the same boat, wanting to understand more—about themselves, about others. There are also many attempts to sate this demand. Amidst all this work and desire, the big challenge is finding a way to talk about what these offerings can and cannot do.
There is no shortage of games about anxiety and depression. The past year and a half has seen an explosion of small, personal games, all of which sought to address this subject in their own way. These titles’ characteristics do not all overlap, but that is precisely the point. Specificity can serve as an antidote to generalized claims about empathy.
Zoe Quinn, Patrick Lindsey, and Isaac Schankler’s Depression Quest is a game about depression (duh!) but it is more importantly a game about language. The second-person text-adventure’s player surrogate is known only as “you.” All relationships are mapped relative to you. You are at the centre of this story, but that doesn’t mean you are in control. The specific challenges you face are largely built into the game’s mechanics; there’s relatively little you can do to create or avoid them. Of course you can make things worse. You can always make things worse. This choice structure matches the game’s description of how depression works.
Depression Quest does not subscribe the narrative convention of “show, don’t tell.” It is a series of moving diktats: you feel this; you feel that. The game doesn’t trust you to piece together the leaps made by a brain that is in crisis, and why should it? The whole point of the exercise is to map out the sequences a depressed mind runs through. These sequences aren’t logical per se but they have an internal logic. One thing leads to another and before you know it, you’ve spiraled into a pit of despair. There’s some good news on the other side, but you’d be lucky to break even in the end.
Nicky Case’s Neurons is perhaps best understood as the story of Depression Quest told from a different perspective. Neurons also maps out the linkages made by a depressed brain. Instead of thinking of these connections in terms of words and scenes, Case diagrams them in accordance with the underlying intuition of cognitive behavioural therapy. This approach to psychotherapy views depression as the product of linkages between stimuli and feelings, behaviours, and thoughts. Those connections can be reprogrammed over time. Neurons has you do just that by clicking away and introducing new stimuli and linkages. This is what characters in Depression Quest are hinting at when they encourage you to seek help: your context is all broken, go make those new connections. This is much easier to do in the context of Case’s interactive diagram than in the midst of a crisis, but the underlying intuition is the same.
Of course, depression and its cousin, anxiety, make much more sense in purely intellectual terms. One can suffer from many of their symptoms and understand what they mean in the abstract without being able to put this information to use. In practice Case’s cognitive behavioural therapy approach takes time, and lots of it. You don’t simply pass a test proving you can draw the diagram of how different stimuli are linked on the back of a napkin; you actually have to reprogram your thinking. Interactive experiences don’t really exist along that time horizon. Games can hint at how that process works, as Neurons does, or show why it is needed, as Depression Quest does, but they are not standalone forms of therapy.
Understanding how depression works, however, leaves the player a long way from knowing what the condition actually looks like. Is it just a bottomless pit of blackness, or does it take on an altogether different appearance? This question is at the heart of Open the Door and Smile, a game created by Arne Bezuijien for the 33rd Ludum Dare games jam. The game attempts to put you in the shoes of a woman in the midst of a custody dispute with an abusive former partner. This state of affairs sends her into a spiraling bout of anxiety. Unlike Depression Quest, Open the Door and Smile renders its protagonist’s world in 3D Space. This graphic choice affects the game’s language; whereas Depression Quest is constantly telling ‘you’ where you are, Open the Door and Smile uses visuals to situate the player, allowing the narration to proceed in the first person. As the game’s protagonist spins around her apartment in search of pills and peace, the walls tessellate and turn into razor-sharp shards. At first, this feels like a rendering bug. Over time, however, the distortions of Open the Door and Smile’s built environment come to match the state of its protagonist. This is not what the apartment actually looks like, but it is what it looks like for her.
(The apartment is not the only place Arnage blurs the line between performance glitch and narrative technique. My award for best update note of the year goes to the latest version of Open the Door and Smile for “Fixed a bug that caused severe performance drops when the player reached high stress levels.” In a game about anxiety, is that really a feature or a bug?)
You cannot know what it is like to be any of these protagonists from these titles’ combined playing lengths. There is obviously more to their struggles than can be fitted into a game. That reality does not, however, preclude learning something along the way. Depression Quest, Neurons, and Open the Door and Smile are all attempts to think about the different forms of reasoning one engages in while suffering from depression or extreme anxiety. These are not comprehensive trips into the brains of others, but they are diagrams of how their brains work. If nothing else, it’s a start.
The differences between games about anxiety and depression are as instructive as their commonalities. The most common difference is the triggering event for each episode. Neurons is a purely theoretical exercise, the fear of an abusive partner and losing one’s child triggers Open the Door and Smile, and past traumas lurk beneath the surface in Depression Quest. Indeed, a game can examine triggers without putting you in the shoes of its protagonist. Manos Agianniotakis’ An Interview turns a man’s story of depression into a third-person interactive feature. There are text prompts to click, but they accomplish nothing. This is the protagonist’s story; you may want to change its course but that is not your place or within your power. The sub-genre of games about depression and anxiety does not come anywhere close to covering the full range of potential triggers, but the mere existence of diversity within the genre is a useful point in and of itself.
Each of these games combats the platitudinous nature of discourse around mental health by telling one specific story and not attempting to stretch that story past its limits. By dint of these stories’ limited scope, they also have limited explanatory power; they tell you some things about depression or anxiety in certain scenarios and nothing more. Depending on the player’s imagination, this may be enough to generate a more generalized sense of empathy, but there can be no guarantee of this outcome. As with Case’s diagram, everything depends on how you connect the dots.
Every Friday, the psychotherapy group meets in the basement of a building that can only be described as brutalism’s lowest moment. It has no windows and the heating only works at the most inopportune moments. The group doesn’t need any further reason to fidget, but the environment obligingly provides one anyhow. There’s a filing cabinet in the corner of the bunker. As best I can tell, it does not contain a single file but does an excellent job propping up the Kleenex stocks, thereby justifying its continued existence.
The advantages and drawbacks of group therapy tend to be evenly balanced. In return for the ease of booking an appointment, you have to accept that much of the session will be spent on concerns that have little relevance to your life. The answer to “why can’t I give public speeches” interests me as little as “why can’t I get out of bed” interests some of my peers. That’s the deal we’ve all made. The real benefit of the group session, however, has very little to do with the actual questions and answers. There’s comfort in looking around a table and seeing people who are dealing with similar issues. I don’t wish any of their difficulties on them, but it is nonetheless reassuring to know that there are other people out there dealing with similar issues. The presence of others is the closest I get to contextualizing how I feel about life and answering my recurring questions.
This group therapy dynamic also describes the last eighteen months of games about anxiety and depression. All of these works are in conversation with one another, but messily so. They talk past each other, raising their own issues and searching for their own answers. Artistically, they fidget in a difficult climate. Yet the existence of all these faces around the table is nonetheless helpful. Even when these games are talking past one another, they contextualize each other by virtue of their existence.
I don’t want to be happier. I’d gladly settle for that, but it’s not a real goal. Instead, I only wish for a bit more perspective, just enough to get through the day with a minimum of fuss. The same is needed from videogames: A little more perspective on what they can and cannot tell us about others or ourselves. As in other media forms, anxiety and depression aren’t signs of artistic seriousness—you can be a serious artist or author without these afflictions—but they are challenges that should be taken seriously. We now have enough games to form a group therapy session and hope some greater context comes of the exercise. That context is needed—it is one of the few areas in which I am confident of not being alone.