Leveling up: Can video games treat mental illness?

For decades, gaming was considered a public health issue. Now, psychologists are starting to research the medium's clinical potential.

"You will die, constantly and without respite." That's what IGN had to say about Dark Souls, the flagship title of Japanese developer FromSoftware, when it first hit stores over a decade ago. In case you're unfamiliar with the property, it's a fantasy RPG that has since become infamous for its uncompromising gameplay, unforgiving level-design, obscure storyline, and much, much more.

Looking back, it makes sense that a video game that took certain death for both its theme and slogan managed to pique the interest of people suffering from depression, a condition that tends to render you incapable of thinking about anything except your own impending doom. What does not necessarily make sense is that many of those same people ended up claiming it changed their mindset for the better.

"Dark Souls came into my life at just the right time," Hamish Black, the creator of the YouTube channel Writing on Games confessed in a video. As he put it, playing this incredibly challenging game convinced him that "it was alright to keep fighting through what I originally saw as unbeatable, and has led me to a point where I am making good progress in tackling my illnesses."

He wasn't the only one who felt this way. Over the years, hundreds of gamers have taken to social media to describe why the dark, dreary and dangerous atmosphere of the Dark Souls games mirrored their own morbid impressions of reality, and how beating their demons in the virtual world might have given them the push they needed to do the same in the real one.

Nor is Dark Souls the only game which has affected players in this way, for that matter. Suspiciously similar stories have surfaced regarding other fantasy titles like The Legend of Zelda: Breath of the Wild and RPGs such as Fallout, not to mention the popular augmented reality app Pokémon Go or the social simulation series Animal Crossing. But what could be the golden threat connecting them?

“You will die, constantly and without respite.”

In a 2010 issue of The Sun, pop star Miley Cyrus called for a ban on video games because they allegedly fostered depression, especially in young people. Her opinion was far from controversial; in the handful of decades that video games have been around, they have been blamed for contributing to some of modernity's most pressing issues, including mass violence, social isolation, obesity, and addiction.

Consequently, parents, journalists, and politicians alike were led to think of your average gamer as an unemployed, unsociable, overweight couch potato—someone who spends their days (or, in most cases, nights) pretending to be a warrior from some or other non-existent place whilst duly avoiding their real-world responsibilities, and probably nurturing nuggets of repressed rage, too.

This haunting image of video games — and the people who play them — has become so ingrained in the public sphere that psychologists have found it difficult to approach the medium from any other angle. But while studies into the clinical aspect of games continue to be regarded as somewhat controversial within the academic world, an increasing number of scholars are beginning to look into their hidden potential.

When Dr. Michelle Colder Carras became interested in video games, she started from the same place as many other researchers: gaming disorders. Then one of her studies discovered that some veterans are using video games to deal with the symptoms of post-traumatic stress disorder, with first-person shooters, in particular, doubling as a form of therapy that could ease their transition back into everyday life.

"Many veterans miss the clarity of the military setting," Dr. Carras explained to me over a Zoom call. "The real world can be a lot more nuanced than military life, and it's not always clear what you should do." One of the subjects she had interviewed said he liked playing games because they help "things make sense again… you know, good, evil. Evil is evil; you stomp it out."

This kind of clarity has not just proven helpful for former combatants. Whereas personal problems often seem as though they are too large and multifarious to confront head-on, video games provide players with clear-cut objectives the completion of which is all but intuitive. Needless to say, the act of doing so has shown to provide them with confidence, assurance, and independence.

“Evil is evil; you stomp it out.”

Coincidentally, this sense of accomplishment makes up an important part of what is known to clinicians as the PERMA model. Devised by American psychologist Martin Seligman, it is a theory of flourishing mental health that's made up of five components (the others being positive emotion, engagement, relationships, and meaning), each of which happens to correspond with a particular pillar of video game design.

Even though developers generally strive to sell as many copies of their games as possible, the fun they provide customers in the process is by no means pointless. In 2008, a study by the Harvard Medical School Center for Mental Health and Media found that many people played video games to relax and knowingly turned to their consoles as a means of regulating their mood.

A lot of video games revolve around players improving their in-game characters, like using experience points gained while playing to increase abilities, upgrade armor and unlock new skillsets. Such mechanics not only force them to adopt a position of self-care, but also make the player feel productive insofar as it actually allows them to make tangible, traceable progress within the virtual world.

I might be preaching to the choir here, but gaming has grown into an incredibly social pastime. Thanks to headsets and Wi-Fi networks, gamers can now play in large groups and communicate with each other while they do so. As such, it was only to be expected that researchers uncovered a link between online interaction and the formation of social skills, especially among those who are too shy to mingle in person.

Last but not least, games can give you a sense of purpose when you think your life has lost its meaning. It can be found in the events hosted by massive online multiplayer games, the guilds and communities of RPGs, and even within the solitary quests of singleplayer experiences — that is, so long as the player believes they have become a part of something larger than themselves.

Inspired by these insights, a number of developers went on to craft games that placed mental health at the forefront of their production. In the self-styled AAA indie title Hellblade: Senua's Sacrifice, for instance, players step into the shoes of a Celtic warrior woman suffering from psychosis, with the various voices inside her head serving as both a driving force for the story as well as a design principle of the gameplay.

Meanwhile, researchers are dissecting commercial video games in order to construct their own. GEMH Lab at Radboud University Nijmegen recently developed a game to teach youngsters how to cope with rejection, something people with depression often struggle with. Though they were inspired by the meditative video game Journey, their final product — titled ScrollQuest — ended up looking a lot more like Dark Souls.

Set in a fantasy world, its players must traverse several combat stages alongside a team of fellow gamers. After each gauntlet, they get to stop at a campfire (or should we say: bonfire) where they can rest and reflect on their performance. If they performed poorly in the previous fight, their teammates might choose to exclude them from the next one. That confrontation would then serve as the first step of the healing process.

"The idea of exposing people to difficult situations in order to help them get through it is not new," Anouk Tuijnman, one of the game's creators, told me during an interview. "It's used in counseling all the time, and to great success. Because video games have the potential to elicit strong negative emotions and create difficult situations that feel real, we thought they would be a good medium to use."

But games are complex things, and that makes them tricky to use in a scientific setting, where the effects of every little detail must, ideally, be rendered quantifiable. The ScrollQuest team discovered as much when their game turned out to be a valuable tool for drawing out feelings of rejection, but — in its current form, at least — unable to measure, let alone improve that kind of behavior.

"Each game fulfills a different need for a certain person," Tuijnman went on to say. "Candy Crush, for instance, can be really soothing for some people, providing distraction and relaxation during difficult times in their lives. Dark Souls can teach people perseverance, which can be helpful depending on their situation. So I don't think there's one particular genre that can be helpful for treating depression."

“Each game fulfills a different need for a certain person.”

Such treatment is made all the more difficult by the fact that, as a variety of studies have indicated, video games tend to be of help to people who play in moderation, but harmful to the ones that game excessively. Since depression nudges you toward the latter of these groups, it would seem as though the medium can be of little use to precisely those who are most in need of help. And yet, this might not be the case.

"You need to treat you need to treat the direct cause of the most serious harm," Dr. Carras, thinking back about her own training in psychiatric epidemiology, pointed out to me as our conversation came to a close. "If someone is using video games as a way to escape, it may be more appropriate to treat whatever is prompting them to do that in the first place."

Since a cure for depression has yet to be invented, it goes without saying that we probably won't see the invention of a game that can treat the condition anytime soon, and even the most hopeful of experts have stressed, over and over, that the medium should not replace conventional therapy. Nonetheless, more of them are coming around to the notion that it could — if used responsibl — assist in the process.

At the end of the day, depression remains a monster of draconian proportions: old, powerful, and shrouded in mystery. Like the bosses that inhabit the dungeons of FromSoft's franchise, it may seem, on many occasions, impossible to defeat. Yet through determination, dedication, and bravery, victory can be achieved. Probably not after the first try, or the second. Maybe not even after the millionth one. The trick is to keep trying.

Praise the Sun!