Gaming's new frontier: Cancer, depression, suicide

How "empathy" games are striving to make powerful emotional connections

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Brian Ramage has made traditional hardcore games for all his professional life, and still does. He recently encountered a very different kind of experience, one that altered his view of what games can achieve.

Attending the Game Developers Conference last month, Ramage was invited to a game developers' social gathering. Anticipating the pleasure of enjoying a few drinks and some amiable conversation with fellow professionals while playing a few demos, he agreed to attend. At the bar, he joined in the hubbub of chatter about games. At some point, he began chatting with a couple of guys working on an unusual project. Ryan Green is the father of a young son who is suffering from terminal cancer. He is making a game about this experience. His friend Josh Larson is helping out.

Sympathetic to Green's plight, Ramage was intrigued. A game about a child's terminal cancer? A game about being the father of a dying child?

Green and Larson showed him their game, That Dragon, Cancer. Ramage sat down facing the bustling room, put on the headphones and played for a few minutes.

That's all it took. He began weeping.

Brian Ramage isn't the kind of person who sniffles at heart-tugging TV commercials. If, at the end of a mushy movie, he feels a tear forming, he'll bite that bad boy back before his girlfriend sees what's what. He's been playing games for most of his 38 years, been making them half his life, and has never, ever cried while playing a game.

He was astonished to find himself weeping in a public place, in a room full of fellow professionals. Green placed a hand on his shoulder. "It's OK," he said. "I understand."

Ramage knows that, when it's completed, he's going to play That Dragon, Cancer. He regrets that the emotional reaction to the game prevented him from exploring it more at the party. He does not regret crying.

The demo places the player as Ryan, a distraught father standing in an intensive care unit while his child lies in a hospital bed suffering from the side effects of cancer treatment. The player moves about the room, interacts with physical elements, experiences Ryan's thoughts through monologue and poetry, but also hears the dreadful sounds of the ICU, of the suffering child.

"I felt like I was really in the room," says Ramage. "Because I was interacting with the room, I felt like I was in there. And then hearing it in his voice, the way he said it. It was raw. It was a father explaining the situation that he's in. I'd never been affected like that before in an interactive experience.

"I'm not a father, but I think I'm sensitive to when I see children in particular suffering. I remember telling [Green] that specifically. I said, 'This isn't supposed to happen to kids. It's just not right, for something like that to happen to a kid."

Other people simulators

What does it feel like to face the death of a child, or to live with hopelessness, or to suffer from the bitterness of extreme loneliness? Fiction and art have grappled with these issues for centuries. Now games are showing us what it is to exist at the extreme margins.

A new generation of games, like That Dragon, Cancer, Depression Quest and Actual Sunlight, is connecting players with real human issues, including terminal illness, depression and suicide. Mostly generated by small teams or by individuals, these games are described by Lucas Pope, creator of Papers, Please, as "other people simulators" that allow us to interact with the world from a challenging point of view.

While games have traditionally endowed the player with a host of impressive fantasy powers, these games show how their creators cope with real-life difficulties, often with a limited ability to effect change. In demonstrating specific challenges via game mechanics, they allow us to walk in other people’s shoes. Developers are showing a deeper understanding that by connecting the player with the storyteller through actions, as opposed to the anecdote, confession or demonstration of more linear forms, they can convey strong feelings or empathy in unique ways.

Joel's story

Joel is 4. He has an infectious laugh, loves to cuddle with mom, with his three siblings and with his dad, Ryan Green. He's a happy, fun boy.

He has cancer and he has it bad. He's been fighting this illness for three years; has beaten seven tumors. Now he's fighting his eighth.

"We're in a culture that doesn't like to talk about hard things," Green says, explaining why he'd make this traumatic experience into a game. "We don't like to remember those things that have shaped our lives, even though they've been the most pivotal points in our histories.

"I think [the game] is important because I think my son is important. Joel may not change the world, but he changed my world. When people deal with hard things, it changes their world. If we share those things, then we can overcome struggles."

That Dragon, Cancer is an exploration of Green's struggle, his inner life. It places the player in the role of a man coping with one of the worst things that life than can throw at a human being. The game does not give you special powers. There are no paths towards resolution. The player explores raw and difficult emotions.

The ICU scene was chosen as a GDC demo because it was especially difficult. Ramage wasn't the only person deeply affected by the game when it was shown to press and to other developers.

Ryan Green made That Dragon, Cancer about his son Joel's terminal illness.

"A few weeks after they had first told us that Joel was terminal," says Green, "he was on some palliative chemo treatment. His ability to fight infection was suppressed by this chemotherapy.

"He caught a stomach bug, and had diarrhea and vomiting. He very quickly became dehydrated. I was there that night when we hospitalized him. He was in a lot of discomfort and pain. That was one of the darkest moments of my experience in this whole thing with cancer. I've re-created that experience, to show people what I went through — to give them a glimpse into what gave us rest in the end."

Josh Larson is working with Green on the game. The two are friends and have collaborated before. Larson is fascinated by gaming's power to deliver human experiences. He says he's inspired by the idea that artists have always used their work to connect people in the deepest ways possible and that games are now ready to tackle the rawest of human outlooks. "My passion is to explore absolutely everything that we possibly can in video games," Larson says.

Larson believes that games can and should be "exploring parts of life that deal with complex issues"; that the player is left with more than merely the enjoyment of the game, but something that fills a role of "transcending the experience of consuming the media itself."

Judging by initial reactions — That Dragon, Cancer was named one of the 10 best games shown at GDC by Paste — the game is able to reach players in ways that are different from power-fantasy games, separate from novels or movies that cover the tragedy of cancer.

"The scariest feeling was realizing that I had done something that connected with people emotionally," says Green. "They may be weeping or they may be very quiet and reflective. You realize that you've reached in and wrenched their guts. I connected with another soul. I did this."

"When people deal with hard things, it changes their world. If we share those things, then we can overcome struggles."

Ryan believes that games' ability to offer choices creates a conversation between the creator and the player, one that's missing from more traditional forms of storytelling.

"By definition, you're entering into a relationship with the viewer," he says. "When you're in a relationship, the dynamics change. Game developer Raph Koster said in a recent essay that games are the only medium in which you can change the gamer's mind. As creators, we should be interested in that.

"I want to create games with nuance. Even if I, as a creator, give limited choices, they still allow the player to enter into a relationship with me. We can have very meaningful discussions in a game space."

It's about changing worlds

Ian Bogost is a professor of media studies, a game designer and the author of Persuasive Games: The Expressive Power of Videogames. For many years, he has been talking about how games can have immense power as communicators of ideas.

"When you read a book or an essay or watch a film, you may empathize with or relate to or otherwise have feelings for the characters or situations," says Bogost, "but you're not in a position where you're making choices and being faced with the experience that the character or situation presents.

"In a game, you've got some model of the world that you play a role in. You've got some part of the world represented in the game and you can make decisions. Those decisions matter in terms of the aesthetics of the experience.

"That idea is pretty powerful, because it allows games to offer these little models of parts of the world that we can step into. We can experience what it's like to be somebody or some other thing. In the case of games that are about someone's personal experience or challenge with a particular problem or identity, that idea of giving us a sense of what it's like to live in someone else's shoes is maybe a bit more pointed in games than it is in other media."

Zoe's story

Depression Quest by Zoe Quinn is a text-based adventure, written in RPG development tool Twine, in which the player attempts to make choices in the midst of clinical depression. Since its launch earlier this year, Depression Quest has been played by more than 300,000 people.

Quinn says the large number of people who have played the game is gratifying, and the fact that some have taken the option of paying to play the game is pleasing. But she is most affected by the individuals whose lives are touched by depression, who have told her that playing this game helped them.


For example, the man who is struggling to complete his degree in psychiatry. He emailed her to say that the game inspired him, reminded him why he has devoted himself to qualifying as a therapist and helping people.

Other emails are from people with loved ones who suffer from depression. The game has helped those people relate to the struggle that they see, but cannot fully comprehend.

"One of the biggest problems with depression is trying to communicate that to another person," says Quinn.

"[Depression Quest] gets the conversation started between people who might not otherwise be able to talk, which is fantastic. I never thought I'd make anything that powerful, ever."

There are many, like Quinn herself, who suffer from depression, and who say the game has helped them understand that they are not alone. Like Ryan Green, Quinn says the act of creating this game has formed a connection between her own struggles and the audience's.

"It's cool, because my players are giving that back to me and letting me know I'm not alone. I find that the people who've played it just want to tell me their stories. Some of them I've started talking to a bit more regularly. There's a player who backed down from suicide after playing the game. He's back in therapy now. It's crazy, the different levels to which the player/game designer dynamic has gone with this."

She has made games before, but says this one has had, by far, the most resonance with its audience.

"One of the biggest problems with depression is trying to communicate that to another person."

"The fact that I've made something that makes people cry, that makes them start taking their medication again, that makes them back off of suicide — I can't quite process it. It doesn't make sense to my brain. But I'm really, really happy that I was able to make any kind of difference for someone else. It's the best thing ever. The fact that I was able to, even just for a minute, make anybody feel a little bit less alone ... It feels like the best thing I've done, ever."

Of course, other entertainment forms create bonds between creator and audience. They inspire action, reform, empathy. Quinn says there's something different about a game, though.

"Whenever you play a game, it's demanding empathy from you. You have to at least imagine what it would be like to be in this situation and immerse your identity somewhere else for a while.

"With something that isn't interactive, you can do whatever and it doesn't matter to the piece of art that you're consuming. With games, you have to give something back. The interactivity demands it, whether it's just button inputs or decision-making. It requires you to engage on a different level."

Designing empathy into popular game mechanics

Games that tackle difficult subjects may not be designed to be fun, in the normal sense of the word. Depression Quest and That Dragon, Cancer are not fun.

But as games mature, as the people who play them and who make them yearn for stories that embrace the human condition, designers are finding ways to talk about important issues while retaining a traditional gaming dynamic.

In Tourette's Quest, the presence of monsters increases your stress, inflicting random symptoms.

Lars Doucet is the man behind tower defense game Defender's Quest. He has Tourette Syndrome. Not the rare, yelling out swear words kind that you see on TV documentaries, but the more widespread kind, of facial tics, especially exacerbated in stressful situations.

He says that, as he has aged, the condition has diminished and he has learned to live with it. But he wants to explore what Tourette's means to people via a roguelike (overhead view, randomly generated room-exploration) game, called Tourette's Quest. The player enters a room, and, depending on how many people (enemies) are in the room, develops tics that must be overcome, impediments to progress.

In real life, people who suffer from Tourette's must face the hazards of meeting new people, of dealing with their reactions, and this can make socializing extremely difficult. Doucet says that a fun game will introduce more people to the experience of what it's like to live with Tourette's, to perhaps then view the condition with more understanding.

"People come to this medium for different reasons," he says. "One of those is entertainment. You wouldn't describe Schindler's List as 'fun.' If you think of watching movies as just entertainment, Schindler's List is going to violate that for you. If games are going to be a serious medium, then I think they can be more than just entertainment. My particular design ethic is, I like to make games that work on the level of entertainment, but also on other levels. Other developers obviously will have different goals and that's totally valid too."

He says that although Defender's Quest is a successful game and his full-time job, everywhere he goes, people want to talk about Tourette's Quest, which is a side project. There is clearly an interest in games about real-life struggles.

"It sparks the imagination. For me it's hard to relate to because Tourette's is very mundane to me. I live with it every day. I forget that it's really exotic and fascinating to other people."

Evan's story

Evan Winters is a 28-year-old white-collar worker living alone in Toronto. He is unhappy, angry. He hates his job. He hates his life.

On the outside, he seems affable, even funny, but his inner conversation reveals a disagreeable man who despises other people. He lives his life through video games. He is terribly lonely.

Evan Winters is a fictional person, the central character in Will O'Neill's game Actual Sunlight. In the game, Evan goes to work, returns home, lives his life, interacts with objects that reveal inner conversations and memories, some of which the game later reveals to be false. He considers suicide.

O'Neill says the game is semi-autobiographical. He also says that while he has no objection to games that set out to foster understanding, to help people, he sees Actual Sunlight as no more, or less, than an artistic expression.

O'Neill's Actual Sunlight is a semi-autobiographical game about his own thoughts of suicide.

"Games are art and they should be entitled to address any subject that any other artistic medium could. It's great to have games that say, 'We made this because we want to help people with Condition X.' But the only thing that makes me worried is that it's almost a conceit. It's almost saying, 'There shouldn't be a game about anything unless it's to help people, unless it has some utility.' That's a natural perspective, because games do have great utility. They have a great ability to teach and act in that role. But I also feel that they're art. Games should be able to address any subject that a film or a movie or a book would."

O'Neill has played games all his life, but he has never made one before. He is a writer by trade. So why write a game, instead of a book or a movie?

"There's something inherently empathetic about the mechanics of controlling a player on screen," he says. "There's something that lends itself to being in that position of the character that allows you to start going into their inner mind and making it feel like you really are in their shoes. It's a powerful medium in that regard, especially for portraying a first-person perspective.

"In terms of the way a player has agency over that character, you can diminish the agency over time to really reflect something powerful that's happening in the mind of that character. I guess I'd call it mechanical empathy, the way that they can put the player into the shoes of that protagonist like no other medium can."

It's a struggle

As well as receiving affirming emails about her work, Zoe Quinn has also received messages from people who do not believe that games should be tackling difficult subjects. They see games as fantasies that allow us to escape the real world.

"There's a sort of inherent stigma and pushback right now," Quinn says, "at least in terms of mainstream gaming attitudes against, especially, interactive fiction and serious games. There's still this broad notion that games have to be fun."

It's an argument Ian Bogost has encountered many times, mostly from a small but noisy section of self-identifying gamers. But there's also another audience, the people who watch movies and read books and listen to songs about real life and the difficulties it often brings.

"Anybody who has been shaped by loss or grief or pain or suffering can identify the very human things in this game and come along with me."

"Generally speaking, people are open-minded and curious," Bogost says. "I think we have a skewed and discordant perception of that curiosity when we spend too much time within the insular games community." He believes that, as more "empathy" games appear, consuming them will become normal, in much the same way that the large number of documentary movies made in recent years has driven growth in that genre. These games may become the self-help section of gaming.

Anecdotally, it's something that Ryan Green has seen, too, this realization that games aren't just power fantasies, but are stories about people.

He tells a story: "I was talking to our hospice therapist. I told her I was making a game. She says, 'Well, I'm not really a gamer.' I said, 'I'm making a game with poetry and music and voice-over. You're in a hospital and you're reliving one of the darkest moments of my life.' Her eyebrows went up and she said, 'Oh. That does sound interesting.'

"Anybody who has been shaped by loss or grief or pain or suffering can identify the very human things in this game and come along with me. That's one thing that we're trying to do. We're trying to remove those boundaries."

Editing: Russ Pitts, Matt Leone, Charlie Hall
Design: Warren Schultheis