Game Studies

Beyond Winning: A Situational Analysis of Two Digital Autobiographical Games

Abstract

This paper examines two digital autobiographical games, That Dragon, Cancer and Depression Quest. Autobiographical games are playable narratives based on the authors’ or designers’ lived experiences. These games were chosen because they share situations that are difficult, dire and/or beyond control. Two researchers evaluated the two games independently as case studies. The purpose of researching through case study methodology was to develop a list of elements and common themes that could then be further empirically studied. The researchers apply Upton’s (2018) situational game design framework, a lens that considers the heuristics in players’ minds before and between actions, while also considering the case studies in light of research on games and empathy and compassion. This research is intended to fill an important gap because it helps us to identify game elements to evaluate further so that we can better support and care for those managing difficult situations. Four themes emerged from our analysis of the two different games: (1) restrictions of player agency, (2) forced failure, (3) pause points in each game that may allow for player reflection and (4) messages of hope.

Keywords: autobiographical games, empathy, failure, illness narrative, player agency, situational game design

Introduction

This paper examines two digital autobiographical games, That Dragon, Cancer and Depression Quest. Autobiographical games are playable interactive narratives based on the authors’ or designers’ lived experiences. We selected these two games to analyze because they describe authors’ experiences with circumstances that are difficult, dire and/or beyond control. In Depression Quest, the player is managing mental illness. In That Dragon, Cancer, the player is dealing with a cancer diagnosis, as well as trauma and grief due to loss. Autobiographies (such as ones from literature or the visual arts) are typically personal and expressive, authored to be read or viewed (Couser, 1997; Danilovic, 2019). For instance, patient-authored narratives on pain management, women’s health and heart health provide a space for authors to document their experiences (Nesby & Salamonsen, 2016). Likewise, game designers can use a mix of narrative techniques and game mechanics to share their experiences through a game, such as living with illness, disability, or trauma (Danilovic, 2019).

Danilovic (2019) studied participants who were invited to design games around personal invisible disabilities (e.g., bipolar disorder, depression and social anxiety, attention deficit hyperactivity disorder (ADHD), color blindness, post-traumatic stress disorder (PTSD), shyness, grief and insomnia) (Danilovic, 2019). Danilovic (2019) considered four aspects, or dimensions, of what they called digital autopathographical game making. First was the designer’s self-study--the autobiography and autopathography in practice. Next was metaphorical symbolic-making, as designers used game mechanics to share their experiences. Last was the computational thinking and logic used to create digital games as interconnected systems. Through software code, designers of digital autopathographical games distilled their emotional experiences as procedural narratives (Danilovic, 2019). In Danilovic’s (2019) study, some participants withdrew player agency (or control over their outcomes in the game) to model how illness or medical trauma affects patients. Others created games as a form of expressive therapy similar to art therapy and play therapy in the field of clinical psychology, as the act of making games can be self-therapeutic (Danilovic, 2019).

As applied by Danilovic, “autopathography” is a portmanteau of “autobiography” and “pathology” and originated from the field of literary studies (Couser, 1997). Examples of autopathographies from literature include Prozac Nation (Wurtzel, 1995), When Breath Becomes Air (Kalanithi, 2016) and Girl, Interrupted (Kaysen, 1994). Autopathographies in the visual arts range from Frida Kahlo’s self-portrait paintings of living with physical disabilities to self-portraiture images, or “selfies,” that people share on the internet (Crosby, 2006; Tembeck, 2016). #Hospitalglam (https://hospitalglam.tumblr.com/) is an example of an autopathographical website, a social forum where patients self-chronicle living with illness (Tembeck, 2016).

Initially, we considered using the term “autopathography” to describe the two games, Depression Quest and That Dragon, Cancer. However, we now push back on the use of the term “autopathography” and its application to games, such as ones that relate to disabilities, trauma, or other uncontrollable and unrepairable circumstances. The circumstances given to these authors, such as living with depression, ADHD, or PTSD, or the handling of grief over loss, should not be “pathologized” in any way. Rather, we want to affirm that these circumstances are parts of humanity, even if they are difficult, dire, or beyond repair.

With the exception of Danilovic’s work, there is limited research on the gameplay mechanics of digital games, and how they may contribute to (or limit) empathy and compassion for people experiencing illness and/or trauma. Thus, we want to expand on this area of research.

Our research investigates two existing autobiographical games. We apply Upton’s (2018) situational game design framework, a lens that considers the heuristics in players’ minds before and between actions. Situational game design “takes into account how play unfolds when the player either isn’t interacting or isn’t trying to win” (Upton, 2018, p. 5). Upton (2018) defines these states as anticipatory play, the expectant pauses when players think and contemplate, and consider which choices to take. We use Upton’s framework to help identify the common elements that emerge between the two games, and to consider how these elements might enhance (or even limit) empathy and compassion for those managing illnesses and trauma.

Empathy and Compassion in Digital Games

Empathy is often defined as the projection of thoughts and feelings onto another (Belman & Flanagan, 2010). Empathy is described as feeling someone else’s actual (or interpreted) emotional state, and also involves the recognition that another’s emotional state is different from our own (Decety & Jackson, 2004; Decety & Moriguchi, 2007).

Empathy is a nuanced, complex concept and there have been many different types of empathy identified, which also may vary in use based on the context (Schrier & Farber, 2021; Zaki, 2007). Empathy can be cognitive in nature, and relate to how people think about other’s thoughts, emotions and worldviews (Lamm & Majdandžić, 2015; Majdandžić et al., 2016). Affective empathy defines empathy as connected to emotions and feeling what others feel (Oswald, 1996). Batchelder et al. (2017) observed how cognitive and affective empathy are “partially dissociable constructs” (p. 2), linked together and difficult to untangle.

The capacity to be empathetic does not necessarily lead to prosocial, compassionate, moral, or ethical outcomes (Decety, 2021). People can have selective empathy when they favor situations and perspectives of in-groups over people in out-groups (Batson et al., 1995; Bloom, 2017; Breithaupt, 2019). When ideological rhetoric is used to manipulate followers for political gain, people may be led to develop false empathy for corrupt leaders (e.g., dictators, terrorists) (Mirra, 2018). In media, including video games, movies and literature, villainous characters--those with “immoral personality traits (narcissism, Machiavellianism, psychopathy)”--are sometimes the most popular among audiences (Kjeldgaard-Christiansen et al., 2021). Decision-making that relies solely on empathy may even negatively affect moral outcomes (Decety, 2021). As a result, people may feel empathy for someone or something, but this may not lead to prosocial or ethical outcomes. Thus, as it relates to empathy in action, compassion may be a more relevant term to use (Bloom, 2017). Compassion refers to not just feeling what another is feeling but also acting in a way that supports them, such as nurturing or showing kindness (CASEL’s SEL Framework, 2020; Jazaieri et al., 2014). But despite possible issues with the term and use of “empathy,” research has suggested that something like “empathy” is related to the behaviors and attitudes needed to foster connection and care (Jazaieri et al., 2014).

Can playing certain digital games foster empathy and compassion from players? And, should games try to elicit these responses? Emerging research suggests that games can stimulate episodic memory and imagination in ways that may evoke empathy (Addis & Schacter 2008; Gaesser 2013; Szpunar & Schacter 2012). Narrative imagination is “an essential preparation for moral interaction” (Nussbaum, 2008, pp. 148-149), as it builds empathy between characters and audiences in games (Danilovic, 2019). In books and films, readers and viewers may imagine how characters might feel while reading their stories and perspectives (Gaesser, 2013; Majdandžić et al., 2016). In games, players may imagine how another may feel through reading, as well as through other game elements, like making choices and taking actions (Farber & Schrier, 2017; Schrier, 2021).

Some games may help to encourage the practice of empathy and compassion by having players make choices, inhabit new settings, or interact with others in meaningful ways (Farber & Schrier, 2017; Lepron et al., 2015; Schrier, 2021). One way is through perspective-taking, or taking on the perspective of another person, animal, culture, or object (Darvasi, 2016; Schrier, 2021). Darvasi (2016) notes that in digital games, players have an opportunity to embody or take on the “mental state, points of view, and motivation” of someone from an out-group (p. 3). For instance, in some games, players may need to consider multiple perspectives of an issue, which can result in decreased participant prejudice and less bias toward out-groups decreased after gameplay (Kampf & Cuhadar, 2015). Schrier (2019) and Schrier et al. (2021) investigated how designing games related to identity exploration may also help to reduce biases and enhance empathy and compassion.

In some games, players may engage in role-playing, where they take on the role of a character, such as a historical figure, which can help foster historical empathy (Boltz, 2017; Schrier, 2021). The game series Mission US: For Crown or Colony? is set in Boston at the onset of the American Revolution. In the game, players take on the role of Nat Wheeler and make decisions on his behalf. Playing it may encourage youth to have historical empathy for game characters and situations (Schrier et al., 2010). Building on this notion, Walker and Venker Weidenbenner (2019) observed how video games could “open the doors to true empathy via perspective-taking as well as the opportunity to utilize empathy in abstract realms such as hypothetical scenarios and virtual domains” (p. 121).

Perspective-taking, however, is not the same as empathy, and there are limitations in how games can fully, accurately, and authentically relay the perspectives of others (Nakamura, 2002; Schrier, 2021). Historical empathy and role-playing activities may promote further misconceptions and biases when not designed or used appropriately (ADL, n.d.; Lauro, 2020; Schrier, 2021). Perspective-taking could even be seen as a form of violence, in that we inhabit someone else’s body, thoughts, or views, without consent, and then leave thinking we might understand someone else without truly understanding or supporting their lives (Nakamura, 2020; Pozo, 2018). Games are living experiences; who plays it, and when and how it is played matters. Cultural norms and values around games may evolve, and game designers may need to revisit how their games may have varying reverberations over time. For instance, in regard to these possible issues, the Mission US team continues to revisit their games’ designs and evaluate how to scaffold historical perspective-taking in a classroom to ensure the safety and care of all players (Mission US, 2021).

Empathy and compassion may be evoked when players take agency over choices and then experience the consequences of their actions (Isbister, 2016; Murray, 2017). A game can enable players to feel agency even if they are bounded and limited in their choices. However, sometimes players subvert agency to make their characters suffer, which may result in sadistic pleasure (e.g., intentionally failing to watch Lara Croft repeatedly die in Tomb Raider, killing and abusing the suffragettes in Red Dead Redemption 2) (Gee, 2007; Lyons, 2018). Moreover, sometimes game designers may limit agency to help players understand feelings of frustration and hopelessness (Farber & Schrier, 2017).

The feeling of control over outcomes is part of what distinguishes digital games as a storytelling medium (Murray, 2017). This sense of player agency may also relate to how players project their identities onto the avatars that they control. By controlling avatars, or in-game characters, players need to actively consider how someone else might view the world and then make decisions based on their projected identity (Gee, 2007; Isbister, 2016). However, players may also be applying utility-based decision-making, doing what maximizes their character’s abilities without having consideration for the fiction or the character’s experiential point of view (Sicart, 2009).

When controlling avatars, players may also build relationships with the non-playable, computer-controlled characters (Burgess & Jones, 2020; Harth, 2017; Schrier, 2017). Non-playable characters, or NPCs, can be the enemies that challenge the player, or they can be sentient player guides or friends (Isbister, 2016). Research suggests that NPCs with rich backstories can aid in a player’s ability to mentally transport into virtual game worlds (Burgess & Jones, 2020; Harth, 2017; Ochs et al., 2009). Harth (2017) found that players who had social interactions with NPCs exhibited “virtual empathy” for their virtual game companions (Harth, 2017, p. 19). The participants who stated that empathy with NPCs was not as deep as with real people still reported emotional attachments (Harth, 2017). Schrier (2017) also found that players had deep affection for the NPC mentor, Walter, in the game Fable III, and players may also form attachments to evocative in-game objects like the companion cube in the Portal series (Turkle, 2011).

Controlling avatars and engaging in rich storyworlds in games can also elicit emotions such as guilt, shame, or pride (Farber, 2021; Isbister, 2016, p. 9). Guilt-proneness, or the ability to be receptive to guilt emotions, has been positively linked to people’s empathetic responses (Tangney & Dearing, 2002; Treeby et al., 2016). Mahood and Hanus (2017) found that players who were most immersed in the digital role-playing game Fallout 3 reported feelings of guilt after taking immoral actions in the game, such as blowing up the town, Megaton. It is possible that these guilty feelings can also trigger an empathetic response from players (Mahood & Hanus, 2017).

Playing digital games can support social and emotional development in youth (Farber, 2021). Bréjard et al. (2016) observed that those who frequently play digital games are more adept at regulating their emotions than those who report occasional play; however, those same players may “express their emotions less than irregular gamers” (p. 347). One example of a game that may induce emotions from players is Spiritfarer, where players help ferry the recently deceased by granting their last wishes (Schrier et al., under review). On the other hand, games may also emotionally overwhelm players, which may contribute to feelings of helplessness, or even further stigma and bias (Nario-Redmond et al., 2017; Schrier, 2019). It may even keep players from continuing to play a game (Schrier, 2021).

Thus, the relationship between games and empathy is complex. While some research points to the possibility of cultivating empathy through games, there are many limitations. Even if a player practices empathy in a game, it does not mean they will act compassionately or behave prosocially in a game (or beyond). And, some games that are well-intentioned may further problematic behavior, misconceptions, or even harm (Schrier, 2021; Ruberg, 2020). For instance, the poverty simulator SPENT implicitly promoted meritocratic belief systems, leading some players to think that being poor is the result of bad decision-making, regardless of systemic societal factors (Roussos & Dovidio, 2016). Games may inadvertently further biases, stigma and discrimination (Nario-Redmond et al., 2017; Olson & Harrell, 2020; Yang et al., 2014).

Moreover, researchers and designers have problematized the use of the term “empathy” with regard to games and pointed out ethical issues with the use of games to transform players or elicit empathetic responses (Anthropy, 2015; Ruberg, 2020). Do the authors of autobiographical games intend to enhance empathy, or is this a transmogrification of their purpose and impact? Pozo (2018) uses queer and Feminist theory to provide a detailed history and critique of the use and labeling of “empathy games” (para. 1). Their analysis reveals that applying an empathy framework to games may result in the “erasure and appropriation” of people, “emphasizing the differences” in a way that further marginalizes people rather than brings them closer or more cared for (Pozo, 2018, para. 14).

Methodology

Purposeful sampling, which occurred in January 2019, guided the researchers to identify two games to analyze (Merriam & Tisdell, 2015; Patton, 2014). Specifically, the “Featured Games” list on Games for Change’s website was reviewed. Of its 175 titles, two digital autobiographical games about the designers’ own lived experiences on illness and/or trauma were curated. These games were: That Dragon Cancer (Numinous Games, 2016), which shares a family’s story about losing a young child to cancer and Depression Quest (Quinn, 2014), a text-based interactive story about living with social anxiety and depression (see Table 1). These two games were specifically chosen because they share narratives on difficult circumstances related to managing illness and/or trauma.

This study is not meant to be exhaustive and, as is typical of case study research, results should not be generalized to a greater population or different set of games (Charmaz, 2014; Creswell, 2017; Yin, 2017). We acknowledge bias in our sampling and curation, as the games studied were produced in the United States by English-speaking design teams.

It is further noted that That Dragon, Cancer and Depression Quest do not solely tell the story of illness and trauma; in part, each shares the authors’ personal experience with all different circumstances and relationships, such as ones with family and friends. We want to affirm that going through any type of mental illness or trauma should not be seen as pathological, as these are parts of human experience. Self-narratives on medical trauma are a form of autobiography, which is where our focus, in this instance, solely centers upon (Couser, 1997; Danilovic, 2019).

Table 1

Digital Autobiographical Games on Illness and/or Trauma

The purpose of researching through case study methodology is to help develop a list of elements and common themes that could then be further empirically studied. This study had two researchers who evaluated each game independently as a single case study. Games were not evaluated in any particular order, and each game took approximately one to two hours to complete. The researchers separately took notes and recorded memos on each game, which developed into themes (Charmaz, 2014; Yin, 2017). Additional data were derived from online artifacts such as game reviews. The purpose of including additional data was to give a complete picture of the games studied. These sources are presented as data in the findings section because they support what was observed during evaluative gameplay. Data were analyzed through Upton’s (2018) situational game design framework, a lens that considers the heuristics in players’ minds before and between actions, while also considering the case studies in light of research on games and empathy and compassion.

Findings

This section shares findings, which are descriptive and presented separately. The case studies are explanatory, meaning that each is descriptive and illustrative. Explanatory case studies “explain how or why some condition came to be” (Yin, 2017, p. 287). After analyzing each game as a single case study, the thematic analysis is shared in the Discussion section.

That Dragon, Cancer

That Dragon, Cancer is an autobiographical game based on two of the game’s designers’ (Ryan and Amy Green) experiences with their young son Joel, diagnosed with terminal cancer at four years old. It can be argued that this game is autobiographical because Joel’s parents were his caregivers and had proxy over his treatment. Thus, the game is autobiographical in the parts where the player-character is one of Joel’s parents, as well as when it relates to the trauma they experienced while engaging in medical settings.

In the game, players take on multiple perspectives, sometimes controlling Ryan (the father), and at other times, like a third-person once removed, seemingly watching the characters from afar but not controlling them. The ability to view and control characters on-screen may enhance players’ capacities to blur their real-life identities with avatars (Darvasi, 2016; Gee, 2007; Isbister, 2016). Taking on multiple points-of-view potentially can also cultivate empathy for the game’s authors as it models how palliative care affects people connected to illness (Timpane et al., 2017).

The game opens with a playful interaction in a park, as young Joel feeds bread to ducks in a pond. Players can explore the playground with Joel, rocking him on a bouncy horse, swinging him in a swing, and guiding him down a slide. These interactions are interrupted with a cell phone call, which pertains to Joel’s head tilting and nausea. On-screen text and narration explain how Joel is slower at doing some things.

Sometimes the game removes agency from the player. In a scene titled “I’m Sorry Guys, It’s Not Good,” the player helplessly watches as doctors tell the parents, Ryan and Amy, that Joel’s brain cancer has returned and is now untreatable. The player cannot take any action and observes helplessly as the room fills with water (the water represents tears). The flooded room conveys a sense of being overwhelmed, as it seems as though the characters might drown. As with other autobiographical narratives, the game employs metaphor, analogy and symbolic meaning-making to convey lived experiences (Couser; 1997; Danilovic, 2019). Also, in the game, there is a vignette titled “Dehydration” where the player controls the father as he unsuccessfully tries to console Joel as he cries. Nothing the player does works: Joel refuses any juice boxes and does not stop crying when Ryan cradles him. Players cannot soothe Joel, just as Ryan could not comfort his son. The lack of agency that the players have in these scenes may help to elicit emotions such as frustration, sadness, grief and helplessness, which could also enhance empathy and compassion for the parents in the game (Farber & Schrier, 2017). Repeated failure can result in learned helplessness, a concept from the field of psychology that describes how people emotionally shut down due to the “inability to control trauma... produced by inescapable shock” (Seligman, 1972, p. 408). In this game, the players face uncontrollable and overwhelming circumstances that were part of the autobiographers’ lived experiences, messaging feelings of frustration and loss to players, but also feelings of hope in that the authors were able to face difficulties, survive and express their stories.

Near the end of the game, in a cathedral, players attend Joel’s funeral. In that space, players are free to explore, play an organ, and light prayer candles. There is no explicit direction to players that they should ever leave that space, to move on to the next and final scene: Joel in heaven eating pancakes with a puppy. Players also often have unlimited time to explore the game’s ethereal environments. Players can slowly walk along a hospital hallway and pause to view hanging photographs of cancer patients. In one vignette, players fill a room with as many inflatable surgical gloves as they like; inflatable gloves then hover over Joel like helium balloons. Given the slow pacing of the game, the game suggests that the player can freely explore grief, rather than “race” to complete it. In this case, the game’s sometimes apparent lack of goals may also be a metaphor for the unknowns that people face in their lives.

Slow pacing in games is sometimes part of games that have environmental storytelling, experiences where players are afforded unlimited time to explore, discover, and reflect as they uncover objects that may reveal parts of a nonlinear narrative (Fullerton, 2018). As Upton (2018) observed, in addition to having explicit goals, some games encourage “expansion play,” where players are given time to freely explore based on their own intrinsic goals (Upton, 2018, p. 70). After expansion play, it is the players who decide their own point of “closure,” the moment where players decide that they have accounted for everything and can move on (Upton, 2018). Closure play means that all of the “collecting, cataloging, and tying up loose ends” have been satisfactorily completed in the minds of players (Upton, 2018, p. 70). Through a situational lens, it left the players to determine when enough hanging hospital wall photographs have been viewed or when surgical gloves have been inflated. 

Ryan Green has described the game as “a living painting; a poem” (Green, 2014, para. 1). His poetry can be heard (as well as seen on-screen) throughout the game’s many dreamscape vignettes (e.g., “Fear is cancer’s preservative, cancer’s embalming oil.”). When digital games transport players into fictional worlds, empathy-related behaviors and actions as part of that engagement can be supported (Belman & Flanagan, 2010; Greitemeyer & Osswald, 2010; Flanagan & Nissenbaum, 2014; Mahood & Hanus, 2017).

The game includes remixes of other familiar video games. In a vignette seemingly out of place with the rest of the game, players race around the hospital wing in a red wagon, in gameplay reminiscent of a Mario Kart game. However, we soon discover that the pieces we are “chasing” in the game are actually the many different types of medicines and tests that the child needs to take. Later in the game, in the scene “Joel the Baby Knight,” players hear Ryan and Amy explain Joel’s illness to their other children. As Ryan and Amy speak, players assume the agency of “Sir Joel,” a pixelated video game character of Joel. In an interaction similar to the side-scrolling Super Mario Bros., players metaphorically (and in this case, literally) attempt to fend off a dragon. Bogost (2017) observed that the aesthetics of games are often the objects and mechanics from other games. Bogost (2017) wrote, “Candy Crush is a game made out of Bejeweled. Gone Home is a game made out of BioShock” (para. 24). The use of familiar video game tropes (i.e., racing, heroes versus villains, winning of points, fighting “bosses”) in That Dragon, Cancer sometimes upends this, suggesting a metaphor for the autobiographers’ disorienting experience with the medical system. Using video game tropes in unexpected, subversive ways can create a sense of disorientation in players (Wardrip-Fruin, 2018). Subversion of these tropes may be modeling the failure(s) of the medical system, such as racing around in circles to collect various medications on a go-kart track in a hospital wing. 

Even though some people may not have experienced cancer and loss firsthand, this game invites players into its world by using universal themes of family, illness and feelings of grief and helplessness, as well as storytelling techniques such as character development, narration, conflict and resolution. The players’ choices do not affect the narrative; Joel’s illness and the eventual outcome cannot be stopped no matter what the player does in the game.

Depression Quest

Depression Quest is a text-based game first created by Zoë Quinn, Patrick Lindsay and Isaac Schankler in 2013, and then published by Quinn in 2014. Quinn has lived with social anxiety and depression and, at the age of twelve, attempted suicide (Parkin, 2014). The opening screen of the game states, “Depression Quest is an interactive fiction game where you play as someone living with depression.” Although not necessarily Quinn, Depression Quest can be considered an autobiography of a lived experience, as players make decisions for a protagonist, who, like Quinn, lives with depression. (While most of the game focuses on the protagonist, sometimes the game also provides more information or “backstory” on other characters, such as the protagonist’s significant other and parents.)

To play, players read brief passages and select from choices about what to do next. Parts of the story lack choice entirely and instead involve players in clicking ahead to progress to the next sections. Some options are banal; yet, because the protagonist is “slowed by depression’s fog” (Parkin, 2014, para. 3), making those choices can be an arduous task. Sometimes players see positive choice options as crossed-out on their screens. For instance, in the beginning, one of the positive choices is crossed out (“Order some food, grab a drink, and hunker down for a night of work.”), whereas the three other (more negative) choices remain (e.g., “Crawl into bed. You’re so stressed and overwhelmed.”). Crossed-out options may increase as players move through the story, illustrating the “downward spiral of depression” (Hoffman, 2017, p. 6). Players of text-based games may expect that all presented choices are clickable; seeing some as crossed-out may be another example of upending player expectations in familiar game genres. As a result, it is possible that players may feel disoriented and possibly frustrated when they encounter crossed-out options (Wardrip-Fruin, 2018). 

The agency players have in games can manifest in different “modes” that are dependent on context (Nguyen, 2019, p. 1). Nguyen (2019) writes that “it might be easier to acquire a mode of agency from a game than from real life. It is easier to start trying out an unfamiliar way of being when somebody tells you exactly what to do” (p. 32). In this game, players may learn about depression because agency is visually illustrated as being constrained, even more so than the limited options (one or more) that players are typically afforded in text-based games. Depression limits a person’s agency; people who suffer from depression or social anxiety disorder may not want to leave their home. Even if they do, they cannot leave their depression. The game operationalizes this through its limitations on the player. The narrative, tone, characters, images, the (limited) choices and gameplay, as well as the look and feel of the game, all work together to relate what depression feels like and how it functions in someone’s daily life. Players can never just “shake off [their] funk and go have a good time with [their girlfriend]” (another choice that is crossed-out) because a person with depression cannot just suddenly feel better no matter what they do. Instead, players sometimes decide between two difficult and even self-destructive choices because that is what a person in that position would need to do. The character is not able to be a confident, friendly and active person. Instead, they are overwhelmed, afraid and unsure.

The game is written from a second-person perspective, with prompts such as: “You are a mid-twenties human being. You have a significant other named Alex, who you are rather fond of that you have been seeing exclusively for the past few months.” Hoffman (2017) argued that the use of “you” is used to help players identify with the main character and also obfuscates the identity of the main character (which could have many different sexual identities and gender identities such as lesbian, bisexual man or woman, straight man, trans man or woman, cis man or woman, non-binary, etc.). The use of “you” is also a text-adventure game convention from the 1980s. It is possible that the reason for authoring in the second person might be to follow that convention. Writing in the second-person may also invite “empathetic play” (Belman & Flanagan, 2010, p. 10). Empathetic players “intentionally try to infer the thoughts and feelings of people or groups represented in the game (cognitive empathy), and/or they prepare themselves for an emotional response, for example, by looking for similarities between themselves and characters in the game (emotional empathy)” (Belman & Flanagan, 2010, p. 10).

Throughout the game, players also get information on their status in three different areas: whether they are depressed, whether they are seeing a therapist and whether they are taking medication. These statuses may change depending on what players choose throughout the story. Otherwise, players can only make choices from the limited options: they can read the story, and see how their choices affect the story as well as these three statuses.

The colors and graphics in the game are also sparse. The game is text-based and has a gray mottled background. The statuses are set in a dark gray and animate like static on an old television set. A Polaroid image of a dark keyboard also sits at the top of the page, buzzing with static. These aspects are part of the game’s paratext, elements outside of gameplay that still “affect how we interpret the text in subtle ways, biasing us toward or against particular ways of engaging” (Upton, 2018, p. 87). Part of the reason for the limited, simple graphics may also be due to making the game “as accessible as possible, both physically and intellectually. It was designed to be inclusive of people without much familiarity with games” (Hoffman, 2017, citing Stuart, 2014).

These are part of the game’s narrative beats, situations within the “story that structures an interpretive choice… [evoking] anticipation of what lies ahead and drifts and wanders as we encounter each new beat” (Upton, 2018, p. 88). While it appears that players are limited in what they can do and have little control or agency over the game, these constraints help to relay what it is like to have depression. As Hoffman (2017) argued, these limitations are an essential aspect of the game. Players can reach an ending where the main character manages their condition with medication and therapy, quite debilitated by their condition, or something in between (Hoffman, 2017). As such, the game may be suggesting that people might have some agency over depression, and that there are strategies that can be taken to help people to better cope, though the journey to coping can be arduous.

Discussion

In these two experiences, there were a number of elements in common. For instance, in each game, players took control of avatars or protagonists who sometimes also stood in for the autobiographers. Each game included events that may be relatable to players’ lives, such as scenes in a playground or in a doctor’s office in That Dragon, Cancer. While not every player has shared the loss of a child, many likely have experienced anxiety at doctor’s offices or hearing medical news. These situations may encourage players to perceive the games’ authors as being similar in ways to themselves in some ways (Belman & Flanagan, 2010). This process is facilitated as each game emphasizes “points of similarity between the player and people or groups with whom she is supposed to empathize” (Belman & Flanagan, 2010, p.11).

In this section, we explore four of the themes that emerged from our analysis of the two different games, including (1) restrictions of player agency, (2) forced failure and the apparent lack of win-states, (3) pause points in each game that may allow for time for player reflection between making choices and (4) messages of hope and coping, amid a difficult journey. We also consider how with these four elements, empathy and compassion may be evoked, and how this may affect our relationship and understanding of the games’ authors. Finally, we problematize the concept of evoking empathy, and ask whether these authors want to elicit it, and whether we should be asking autobiographical games to elicit it. 

Limited Agency

The first two themes across each game are limited agency and player failure, which often go together. First, let’s investigate player agency and limited choices. Some games restrict player agency in ways that players are forced to fail. These constraints, however, may also help players better understand the types of obstacles that the author of a game faces. For instance, Depression Quest is based on Quinn’s experience living with depression and social anxiety disorder (Quinn, 2017). It presents choices steeped in narrative context; following paragraphs of text; some options can be clicked, while others are crossed out, visually illustrating how people with depression and social anxiety disorder may also feel constrained. Players may not be able to access dialogue or action choices, suggesting the unfair limits placed on people with depression, who may be unable to engage with the world as they want to. The limited choices players were given may build empathy and compassion because it helps to relay the more constrained (and even crushing) path that someone with depression would be forced to undertake. The use of visual grammar and the limited affordances conveys “something that words wouldn’t on their own… making the experience of exhaustion tangible” (Clark as stated in Anthropy & Clark, 2014, p. 170).

Empathy may manifest as players “infer the thoughts and feelings of people or groups represented in the game” (Belman & Flanagan, 2010, p. 10). In digital games, code “imposes a hard, external constraint” on player actions (Upton, 2018, p. 16). Such constraints may then allow players to reflect on whether there is ever true agency over one’s choices--as the game hoists conditions on its players, regardless if they wanted it or not.

Second, in each of these games, the narratives were also constrained; as Upton (2018) observed, through a situational lens, “text is a system of constraints” (p. 90). In That Dragon, Cancer, players cannot make decisions that alter the narrative of succumbing to cancer. The lack of player agency over narrative outcomes underscores the feeling of hopelessness that the family feels in having a sick child that they cannot cure or soothe. It also helps to illustrate the Green family’s personal theological struggles, such as whether individual prayers and hopes matter (topics also covered in the game’s narrative; Larson as stated to Clark, 2015). Concepts of free will and limited agency are tied to Ryan and Amy Green’s Christian worldview. No matter what players choose, they cannot change the narrative outcome of this game. The game always ends the same way; players cannot save Joel (Auxier, 2018). This constraint serves to underscore the despair of the Green family and may help to enhance our empathy for them. Narrative constraint may also lead to empathetic concern for the family’s plight (Batson et al., 1995; Upton, 2018).

Forced Failure

These games each share themes about struggling to control uncontrollable, often overwhelming, life circumstances. They express this struggle in the ways that they limit player agency and also force “failure.” As we described in the previous section, players cannot always make the choices or take the actions that they wish. They often fail.

Some digital games force player failure by presenting intentionally unwinnable challenges or limited choices, as the design goal may be for players to replay using different strategies (Bycer, 2014; Kapur & Bielaczyc, 2012). In the games we reviewed, player failure was forced due to both gameplay (e.g., players cannot give Joel the water) and narrative constraints (e.g., players cannot help but be affected by their depression) (Juul, 2013). In each game, designers share personal narratives of facing health-related circumstances that can often not be altered or “won” (e.g., death from terminal cancer). The games are not “winnable,” but rather affirm a path.

Failure in these games may help players better understand how unavoidable and inescapable dealing with traumatic medical experiences feels. In these two games, players are led to tragic or difficult outcomes no matter what decisions are made (e.g., the death of a young child) (Logas, 2011). The games’ authors are able to not just “say” how difficult the journey is, but they enable the player to perform it also, and perhaps, to feel it. For instance, players may experience feelings of hopelessness in That Dragon, Cancer after giving Joel juice boxes and cradling him to no avail. When this vignette was first playtested, players were observed “breaking down in sobs” (Tenz, 2016, para. 2).

Similarly, in Depression Quest, players may feel powerless during gameplay. They see unavailable choices as crossed-out, leading them to select options that may have fewer or no desirable outcomes, such as retreating to bed to sleep all day. In narrative games, “if the text thwarts our expectations, then we experience a crux and retroactively adjust our interpretations to account for the discontinuity” (Upton, 2018, p. 90). Thus, limited player agency (and inevitable player failure) is the message. It helps the player to empathize with a situation where there are no solutions to health problems, as not every medical challenge is “winnable.” In these games, persistence to make it through difficult emotional arcs to a point of resolution may also be the message (Danilovic, 2019; Juul, 2013).

Games that are not winnable may affect how players feel in different ways. For instance, “near-misses” in free-to-play puzzle games like Candy Crush Saga may boost players’ desires to keep playing (Larche et al., 2017, p. 599). Some games presented as unwinnable, like Flappy Bird, may invigorate some players to learn patterns, while also causing disdain in other parts of player communities (Brandão et al., 2019).

But there are also important critical analyses of unwinnable games. Pozo (2018) cites Osit and Zouhali-Worrall (2016) and critiques the ways in which “games you can’t win” are discussed. They argue that these discussions may center the player, rather than centering the games’ author. These discussions focus on what the player needs and does (e.g., winning, accomplishing, understanding, empathizing), rather than what the author needs. This may then remove the agency of the games’ author.

Moreover, using an “empathy framework” to apply to a game like That Dragon, Cancer or Depression Quest may focus on the difference between the player and the author. For instance, asking the player for “empathy” for an author sets up the player as being different from the author, rather than similar. This implicitly focuses on difference, rather than a kindred affirmation of one’s own experience, and may also diminish the agency of the author. “The empathizer becomes the subject, and the object ‘threatens to disappear’” (Pozo, 2018). Using queer and Feminist approaches of these games (and exhibits of the game that include the author of the game) might ensure the author is continuing to be present and have agency over the game, its discourse, and its impact (Pozo, 2018).

We may also want to consider how the agency of authors like Quinn was affected in how their games were targeted; and how sharing the game caused further trauma (Pozo, 2018; Chess & Shaw, 2014). Authors who are already marginalized and traumatized (and want to be able to express and share their full selves) instead become re-traumatized due to the lack of compassion of the games audience and industry as a whole. “While difference and emotional self-revelation had been prized qualities of indie games, women's autobiographical exploration of difficult stories made them uniquely vulnerable. Thus, Quinn’s Depression Quest (2013) came under fire during GamerGate alongside games representing LGBT themes. Transmisogyny was and is central to GamerGate--as continuing “witch hunts” trying to determine if Quinn is trans attest (Quinn, 2017, p. 69). The failure of the industry to support members of the queer games scene during GamerGate (see Quinn, 2017, p. 73) seemed to prove that empathy games had failed to teach fans anything” (Pozo, 2018).

Autobiographies, which are inherently author-centric, may share lived experiences in the face of tragic circumstances that, through their creation, may involve some form of restoration (Danilovic, 2019). But the sharing of these vulnerable stories may cause further trauma instead. Pozo (2018) writes, “Where does this empathy go as designers struggle to make a living from their work, or as their physical safety and privacy are threatened by cycles of harassment for their visibility?” (para. 12). 

While the games we studied may limit agency and force failure for the player, the games’ impact should not limit the authors’ agency. We should reconsider whether we want to ask a game to elicit empathy, and how even including questions of empathy may affect an authors’ agency over their game. An autobiographical game, ultimately, should be about the author and their agency over their story and expression, rather than the players’ agency over its impact. Does an author of an autobiographical game want to enable empathy? Or, are questions around empathy and compassion limiting agency and perhaps even marginalizing the author of the game further? We need to question even the impact of this article, and how it might affect author agency, and how we view autobiographical games and our relationship with their authors.

Agency through Reflection and Creation

In each of these games, player agency over gameplay is limited. But players do have the agency to anticipate play or reflect on previous play (Upton, 2018), by either interacting with the game or taking no actions, doing nothing, stopping play altogether (Anthropy & Clark, 2014). Players have the agency to reflect on the game, its gameplay, and its narrative. The player has agency to stop playing and to decide how they want to play it, even if an ending or outcome is inevitable. Further, each of these games has a heuristic element of uncertainty and interpretive play, elements that afford reflection on actions (Upton, 2018). Upton (2018) writes, “Play is more than just winning. Sometimes, play is performance--it’s trying on different identities or creatively expressing your own personality” (p. 4).

Depression Quest is an example of hypertext fiction, where passages appear on different webpages based on players’ choices (Salter & Moulthrop, 2021). Subsequent passages do not exist until or unless players interact with the hypertext, thus unfolding the story as they provide input through actions like clicking. As such, players may also go back in their browser’s history and possibly advance the narrative differently (Salter & Moulthrop, 2021). Thus, in addition to the reflection and contemplation players may anticipate, there may also be expectant pauses as players can also replay the game, going back and taking different branches in the narrative (Upton, 2018). As a game steeped in text, players may also feel agency in how they interpret Quinn’s passages, even though they may not be able to actually control parts of the narrative itself (Mendelsund, 2014). Thus, as Upton (2018) wrote, “playful situations offer us a handful of moves to choose from, with the number increasing inverse to the relation to the pace of the game” (p. 43). Upton (2018) also observed that written text might not be seemingly interactive, but it can present readers with goals and opportunities to work toward resolution. Further, readers may be piecing together narrative threads in their heads as they read (Upton, 2018).

Players are not timed in any of these games and can linger on choices or can take no actions at all. In Depression Quest, after reading a text passage, players can click on choices, or linger on the screen doing nothing. The gameplay is slow and contemplative, encouraging reflection between choices. Players can wander in That Dragon, Cancer’s cathedral indefinitely, playing notes on an organ, lighting prayer candles, or taking a pause to contemplate. The only way to exit the cathedral is to stop lighting prayer candles. Thus, players may be able to actively reflect on the games’ stories by selecting story branches, pausing between choices, or interpreting the passages or scenes that precede choices (Isbister, 2016; Upton, 2018). Players of these two autobiographical games are afforded time to reflect on experiences, and through play, accept it alongside the authors, which can feel empowering and also expressive of the condition of living with, and continually being presented with, illnesses and trauma. 

Further, each game may engage players in empathetic responses through a process known as theory of mind (Castano & Kidd, 2013). Theory of mind describes how readers interpret fiction authors’ words in their heads (Castano & Kidd, 2013), which may lead them to project their own identities on the author’s experiences and situations (Gaesser, 2013; Majdandžić et al., 2016). Bal and Veltkamp (2013) suggest that theory of mind may be dependent on the strength of narrative that mentally transports readers into fiction. The two games’ narratives enable reflection between choices, which may support the projective imagination of players to the authors’ worlds (Gaesser, 2013; Murphy et al., 2011; Upton, 2018).

In the previous section, we question whether having a player play a game and practice empathy may limit the agency of an author. But, this relationship may be more complex. A game is a relationship and communication between author/designer and player. Can both players and authors co-develop agency in how they co-reflect on the authors’ traumas and journeys? Trauma and depression have been observed to reduce when artifacts are created by traumatized adolescents and adults (Schouten et al., 2015; Shamri Zeevi, 2021). (Although the effectiveness of art therapy is well established in literature (e.g., Schouten et al., 2015), game design as art therapy, and the effect on those who engage in those systems, is an area that still warrants more study.) By making these autobiographical games, the author(s) are able to reflect on their own journeys, and bring others along to reflect on that journey with them. The possibility of a co-reflective relationship, and how the author(s) can maintain safety, equitable power, and presence in it, should be studied further.

Acceptance Rather than Control

Across each of these games there is a lack of ability to “control” or “win” in the conventional or traditional sense of video gaming, but we can interpret this in multiple ways. First, none of us have an ability to control our physical and mental health, nor the health of others--we are given uninvited circumstances that affect our bodies, minds and relationships. As we have described, including “unwinnable” conditions in these games may help the authors of autobiographical games express their lack of control over their circumstances, such as the outcomes of medical treatments or traumas. No one can ultimately “win,” rather, we must live with the circumstances we are given. Trauma, disease and medical problems are part of the human condition, and games, like other media forms, can help us express these. The games show us that we can face these circumstances and learn to manage the coping mechanisms and strategies to grieve and deal with inevitable pain and loss (Reer & Quandt, 2020; Waterman, 2013).

Second, these games may reveal to us that “winning” is not about overcoming obstacles, but about surviving them, and living with them. Thus, “winning” or “failing” in these game experiences may instead relate to acceptance, rather than control or consumption.

Juul’s (2013) paradox of failure states that people generally avoid situations that knowingly result in failure--except when playing games. Juul (2013) further describes how players have an awareness that challenging game experiences will often end with catharsis, the Aristotelian term that describes purging of negative emotions (Juul, 2013). Catharsis is feeling relief from tense or difficult experiences. In the context of games, as well as in other media forms (books, films), catharsis relates to how people vicariously experience these emotions, free to “fail gracefully” from real-world or actualized consequences (Gee, 2007; Huizinga, 1938/1955; Plaas et al., 2015, p. 261). Engaging with autobiographies may give players coping strategies to deal with loss when tragedy strikes in the real-world (Reer & Quandt, 2020; Waterman, 2013). Couser (1997) wrote, “if illness and disability are reminders of our mortality and frailty, narratives of those conditions are testaments to our resilience and vitality” (p. 295).

Thus, playing these games becomes a form of cathartic resolution rather than an actual, tangible act of completion. It also shows us that people face different significant obstacles, and we need to acknowledge these inequities (Juul, 2013). When Joel passes on, he is shown to be in heaven, saved by grace. We, along with his parents, may not feel resolved or like we “won,” but we can collectively acknowledge acceptance of this outcome. Depression Quest has a possible ending where the protagonist can manage their depression using medication and therapy.

Third, despite the lack of winning and control to affect game narratives, outcomes, or choices, players still have the ability to reflect and interpret, which itself is a form of agency and a way to accept and receive from the author. The player has agency in how they play a game, live with it and acknowledge it. The player can also give the author agency by enabling their story to be expressed. And, the author has agency in how they share their story, and reveal their lives to others. Finally, we, as authors of this paper, can also reflect on these relationships, which itself is a form of agency and acceptance of these complexities. 

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