Cecilia Rodéhn

Cecilia Rodéhn is an associate professor and a senior lecturer at the Centre for Gender Research and Department of Game Design, Uppsala University. Her research focuses representations of madness and psychiatric hospitals.

Contact information:
Cecilia.rodehn at gender.uu.se

Introducing Mad Studies and Mad Reading to Game Studies

by Cecilia Rodéhn


The aim of this paper is to introduce and develop mad studies as a theory and mad reading as a method for examining representations of madness in games. Mad studies is a theoretical field that examines madness and critically addresses systematic and symbolic sanism. In this text, mad studies is positioned as a shift of perspective from previous psy sciences-influenced research to a more inclusive way of studying madness in games. Mad reading is explained as (1) a situated reading, (2) challenging sanist representations, (3) reading the explicitly mad, (4) revealing where madness is not clearly visible, and (5) maddening games. The paper offers suggestions on how to put mad studies and mad reading into practice when studying games. The paper is primarily theory-driven but gives examples from several games, particularly the game Outlast.

Keywords: mad studies, mad reading, mad leakage, sanism, madness, mental illness


Introducing Mad Studies and Mad Reading to Game Studies

Recently, scholars have stressed the need to further investigate how mental illness is represented in games (Gibbon, 2015; Shapiro & Rotter, 2016; Dunlap, 2019; Ferrari et al. 2019; Anderson, 2020). These calls are derived from the fact that scholarly discussion on representations of mental illness in games is scarce. Existing research reveals that mental illness is represented as insanity, fear, violence, homicidal behaviour, and/or hopelessness in games (Shapiro & Rotter, 2016; Gibbon, 2015; Dunlap, 2019; Ferrari et al, 2019; Anderson, 2020) and that psychiatric hospitals are represented as abandoned, dark, disturbing, and haunted places where patients are subjected to experimental and uncertain treatment (Ferrari et al., 2019, p. 8; Fordham & Bell, 2019, p. 2). In various ways, researchers conclude that the depictions of mental illness reflect ableist discourses that work to marginalize those experiencing mental ill-health (Gibbon, 2015; Shapiro & Rotter, 2016; Dunlap, 2019; Ferrari et al., 2019; Anderson 2020). Ableism refers to the belief that the “perfect” body is the norm and disabilities are considered as lesser states of being in need of correction (Ledder, 2019, p. 31). Simon Ledder argues that game studies needs to take ableism more seriously; otherwise, the field runs the risk of “inadvertently perpetuat[ing] the ableist hegemony” (Ledder, 2019, p. 41). This paper seeks to answer Ledder’s call by introducing mad studies and mad reading as ways to examine representations of madness in games.

The aim of this text is to introduce mad studies and mad reading to game studies. I explain how mad studies offers a shift of perspective from psy sciences (psychiatry and psychology) to putting experiences of madness at the centre of the analysis of games. The paper further develops mad reading for the study of games. I explain how a mad reading shifts the perspective from diagnosing characters and examining how diagnosis appears within the game to exploring how and where madness appears in games. Furthermore, I explain how mad reading seeks to address the workings of normative ableist discourses in games and explore how sanism is conflated with other oppressive ideologies in games. In addition, I explain how mad reading works with the tension between what is visible/invisible in games, where the hidden is considered equally important as the visible for understanding representations of madness. This article is primarily theory-driven but gives examples from several games, particularly the game Outlast. The article offers suggestions on how to put mad studies and mad reading into practice when studying games.

Previous Research

Previous research explores the ways in which people diagnosed with mental illness are represented as the other in games. In doing so many different methodologies are employed. Some researchers use quantitative content analysis identifying the number of characters with mental illness in games (Shapiro & Rotter, 2016; Ferrari, et al., 2019). Others use qualitative content analysis coupled with a player-as-analyst approach in order to analyze expressions of mental illness in games (Gibbon, 2015; Fordham & Ball, 2019; Anderson, 2020). Discourse analysis is used to investigate normative discourses connected to mental illness. Sara Gibbon, for instance, uses a disability studies lens. However, except for stating that this approach offers tools that “draws attention to the cultural narratives about normalcy” (Gibbon, 2015), she does not explain or develop the approach further. Others use a game design approach, identifying audiovisual styles, control systems, and game goals, to represent mental illness in video games in order to suggest how to improve game design (Anderson, 2020, p. 23, 30). Game design is also used as a method to examine portrayals of depression and anxiety, utilizing an experiential metaphorical approach (Phelbs, Wagner & Moger, 2020). The purpose is to represent what living with mental illness entails in order to produce meaningful games (Rusch, 2015; 2020; Harris, Shattell, Rusch, Zeefeldt, 2015; Phelbs, Wagner & Moger, 2020).

These scholars have in common that they seek to identify mental illness in games, and this is carried out by diagnosing characters (Shapiro & Rotter, 2016) and looking for representations of diagnostic labels (Ferrari et al., 2019; Fordham & Balls, 2019; Anderson, 2020). Yet, researchers often come to the conclusion that diagnostic labels are used incorrectly (e.g. Ferrari et al., 2019, p. 5). Scholars also use diagnostic criteria and psychological models in order to develop methods or in arguing for a best practice in game design (Dunalp, 2019; Phelps, Wagner & Moger, 2020, Harris et al., 2015; Rusch, 2015; 2020). Samuel Shapiro and Merrill Rotter (2016), Kelli Dunlap (2019), Manuela Ferrari et al. (2019), Joseph Fordham and Christopher Ball (2019), Andi Phelps, Jocelyn Wagner and Andrew Moger (2020), and Doris Rusch (2015; 2020) alike use diagnostic criteria as articulated in psy sciences to examine and compare mental illness in games. For instance, Dunlap (2019) identifies and categorizes mental illness by developing a spectrum approach inspired by diagnostic criteria for psychological disorders. The spectrum approach identifies three levels of representation in games, from flat to multidimensional levels, in order to suggest realistic and deep representations (Dunlap, 2019, pp. 80-83). Phelps, Wagner and, Moger (2020, pp. 122-123) develop a double axis of design elements “examining a range of games from literal to metaphorical, and from realistic to abstract avatar representation” in order to compare representations to mental illness diagnoses. In doing so, they deliver conclusions like “depictions of mental illness in games [are] unrealistic” (Phelps, Wagner & Moger, 2020, p. 122), and this becomes an argument used to propose authentic representations (see also Rusch, 2020). I suggest that mad studies offers a shift of perspective in how mental illness has been researched in games, both in terms of theory and methodology.

A Shift of Perspective

The way that mental illness is approached in the research outlined above suggests that there is something real and authentic out there that representation in games can be measured against. Representations in games are compared to real-life people and/ or diagnostic labels and criteria. There seems to be a belief that representations in games mirror or distort reality in some way. This completely disregards that diagnostic labels and criteria are a language -- a system of representations -- that stand in for that which it seeks to represent (cf. Hall, 2013, for a discussion on representations). Representations are the production of meaning through language (Hall, 2013, pp. 1-4). Diagnoses and games alike can be said to operate as forms of language that mediate meaning and dominant discourses. The manner in which diagnostic criteria is used in previous research entails comparing representations with representations. This completely disregards the fact that diagnostic labels are representations that carry and communicate power and knowledge. Furthermore, using the language of psy sciences means that a representation in games can only mean something within a psy science discourse. A mad studies perspective on games departs from this perspective and focuses instead on what mad people and madness can mean within the game, thus offering a contextual approach. As such, it challenges psy sciences’ ubiquitous explanations of madness.

Mad studies is an interdisciplinary field that critically discusses how the social and medical systems create mental illness (Stefan, 2018, p. 2). The field seeks to critically address how “deviant” behaviours have been pathologized and silenced and how some people continue to be marginalized (Menzies, LeFrançois & Reaume, 2013, p. 1, 13). It seeks to illuminate the systemic and symbolic violence that has been inflicted upon people diagnosed with mental illness in society, which also means exploring the role that cultural representations play in furthering ableism and sanism (Menzies, LeFrançois & Reaume, 2013, p. 3). Sanism refers to the discrimination of people diagnosed with mental illness, neuropsychiatric variation, and/ or people that are seen as having “different” social behaviours (LeFrançois, Menzies & Reaume, 2013, p. 339).

Mental illness is an umbrella term used by the psy science discourse and health services for psychiatric illnesses, mental disorders, and ordinary mental ill-health problems and mild symptoms (Vilhelmsson, 2014, p. 65). However, mad studies scholars prefer the term mad and madness when writing about people and their experiences, as it endeavours to transform the ways mental illness and mad people are talked about (LeFrançois, Menzies & Reaume, 2013, p. 337). The term mad is, thus, an alternative to mental illness and deviant social behaviour (Menzies, LeFrançois & Reaume, 2013, p. 10), and madness can be defined as the following:

A ubiquitous term for a range of phenomena (e.g. violence, extremity, creativity, excellence, chaos) historically used in the West to indicate irrationality, confusion, or distress in a situation or an individual (e.g., mania, melancholy, lunacy). Madness discourse was formulated into psycho-medical terms (e.g., psychosis, depression, asociality) and psycho-legal terms (e.g., insanity, incapacity), but was recently reclaimed for a broader social, cultural, even liberatory approaches to medicalized experiences, especially by people treated involuntarily. (Menzies, LeFrançois & Reaume, 2013, p. 337)

Madness is in this definition positioned as a historical and socially conditioned situation stressing that context matters. The authors highlight that although mad studies seeks to challenge psy sciences’ universal definitions of mental illness, it is nevertheless dependent on it in order to reclaim and redefine madness. Implicit in this definition is that madness can mean both something diagnosable as well as a rejection of diagnoses. Some scholars embrace diagnoses and argue that they can be empowering, whereas others reject them. Mad studies operates with this tension and also embraces it. For this reason, Richard Ingram has pushed the explanation of the term madness even further. He writes that it is not necessary to define madness since “trying to pin madness as one thing is, I think, to miss the point: it is a million things” (Ingram, 2016, p. 15). Ingram’s statement highlights a centrality within mad studies, which is to resist and challenge categories.

Definitions of madness within mad studies can be said to be deliberately ambiguous. Compared to psy sciences’ categorizations of mental illness providing a seemingly logical ordering of symptoms, mad studies seeks to avoid essentializing and determining madness. The fluid definition of madness can be complicated to work with, yet the fluidity is, in my view, a strength, as it puts focus on contexts and experiences. Therefore, mad studies merges well with discussions in game studies, where scholars argue that the context of the game matters for the analysis and that theories and methodologies should not be applied haphazardly (see, for instance, Aarseth [2003] for a discussion on theory and methodology in game studies). Rather than allowing other disciplinary fields to define what madness can be in games, a mad studies approach allows the game to remain at the centre for what madness is and can become. Working with mad studies definitions offers paths to redress the way that mental illness has been researched in games; it provides researchers with a theoretical and methodological perspective to move beyond psy sciences in the endeavour to explore the fullness of how mad people and madness are represented in games. Furthermore, it highlights what games as a medium can contribute to the understanding of madness in a larger social context.

Shifting the focus away from psy science-influenced research to mad studies-centred research on games entails introducing new methods. In this text, I introduce and develop a mad reading of games. Mad reading is a textual analysis for examining literary work, developed by mad studies researcher and literary scholar PhebeAnn Wolframe (2014). Textual analysis, like all methods, has its shortcomings and is best suited for qualitative studies. Furthermore, textual analysis has a complicated history within game studies. Some game studies scholars hold that textual analysis should not be used when analysing games and argue that games are not texts (Juul, 2000). Arguing for a performative approach, researchers propose that games cannot be approached like other media or with methods developed in other disciplines (Aarseth, 2003; Burrill, 2008, pp. 4, 79); it is suggested that “the games require a methodology that attends to their specific qualities as a medium” (Burrill 2008, p. 4). Helen Kennedy proposes that it is insufficient to consider games as texts because it does not allow for an understanding of what it means to play the game (Kennedy, 2002). Furthermore, Phelbs, Wagner, and Moger suggest that games involve play and interactivity, and that “the game is intended to be felt rather than to be read” (2020, p. 114).

I suggest that the researchers’ critiques of textual analysis reveal that they have a very simplified understanding of what the method implies, and they misunderstand what a “text” is. A “text” is not just words on a paper but any object intended to be interpreted as a representation (system of meaning). Therefore, a textual reading, according to Tanya Krzywinska, allows for codes, rules, goals, structures, mechanics that are fundamental to games to be considered as readable texts and it acknowledges that playing a game is also a reading of the game (Krzywinska, 2015, p. 24). Doing a textual analysis of games means that “video games can be studied as meaningful cultural objects” (Archibal, 2009, p. 362), where dominant ideologies and meaning can be revealed (Carr, 2019; Ledder, 2019). This is also what a mad reading sets out to do -- it examines the “discursive conditions of madness’ emergence” and interrogates the boundaries of mad/sane identities rather than allowing ableism to become, and continue to be, the natural order of things (Wolframe, 2014, pp. iii, 2, 237). This includes being attentive to how sanism is discrimination and how it is often conflated with sexism, racism, classism, ageism, ableism, and transphobia (Wolframe, 2014, p. 12).

In this text I build on Wolframe’s mad reading and develop it further for game studies. In doing so, I combine mad reading with strategies from queer reading. Queer reading is also a textual analysis that emerged in literature studies and that has recently been adopted by game scholars (see Shaw and Persaud’s [2020] for discussion of queer reading in game studies). Queer reading can be described as, on one level, reading the visible queer in a text, and as such it sets out to challenge oppressive regimes and work for emancipation from those regimes (Björklund & Lönngren, 2020, p. 198). On another level, it seeks to uncover that which is hidden and invisible in the text (Björklund & Lönngren, 2020, p. 197). It is suggested that all texts that appear heteronormative have a queerness within that can be uncovered (Rosenberg 2002, pp. 117-120). In game studies, queer reading is argued to be an opening for the possibilities to read queerness in games and avail players to establish queer potential in texts (Shaw & Persaud, 2020). It has also been explained as disrupting normative meanings and “subvert[ing] standard expectations” (Bohunicky & Milligan, 2019, p. 52) and seen as a way to complicate representations (Mejeur, 2018, p. 116). Coupling mad reading and queer reading not only allows me to exemplify how mad people are othered in games, but also opens up the analysis to focus on the explicitly mad and the possibilities this holds for reenvisioning madness in games.

A Situated Reading

I suggest that a mad reading of games is a situated reading, a reading that harnesses experiences of madness when analysing games. As such, a mad reading is not only a reading of games; it is a place where knowledge about games is produced -- and potentially produced differently. According to Wolframe, a mad reading entails “reading from the perspective of mad experience” (2014, p. 12). This follows in line with researchers within mad studies who suggest that people with experiences of madness and those having experienced psychiatric care should be at the centre of knowledge production. Angela Sweeney explains that studies on madness and mad people have been conducted in a context where scientists have abused their power for centuries (2016). Thus, it has been emphasized that research needs to be conducted by those that identify as mad (Menzies, LeFrançois & Reaume, 2013). However, a mad identity is not a prerequisite. Wolframe writes that “‘sane’ individuals who have experienced neither madness nor psychiatrization could also learn to think and read from a mad perspective.” This involves learning how to read from the position of madness (Wolframe, 2014, p. 3-4). Reading from the position of madness does not imply trying to act out madness or imagine that one is mad; it does imply taking another’s perspective and read/play empathically from this perspective. “Sane” individuals can access mad perspectives from research found within the field of mad studies, which is often, albeit not always, produced by researchers with experiences of madness.

In order to read from a mad perspective, it is necessary to develop an awareness of the position from where the reading/playing takes place and how this position shapes knowledge production. What I propose is in keeping with what Donna Haraway (1988) calls “situated knowledges,” an approach that attempts to deconstruct the seemingly objective god’s-eye view in science. This is not new to game studies but can be seen in research exploring power structures within gaming culture (Humphries 2019) in the player-as-analyst method, where it is suggested that the researcher should state what kind of player they are since this influences the experience of the game and consequently the analysis (Aarseth 2003), and in developing textual analysis methods where it is suggested that the embodied experience of playing the game generates a particular kind of knowledges (Carr, 2019, p. 717). Game studies and mad studies have in common that both fields call for a situated perspective of the topic investigated.

Approaching madness as a position from where reading can be undertaken also suggests that mad reading is not only a situatedness but also a situation where knowledge is produced. This can enable new and different kinds of knowing about games. In mad studies, the production of knowledge from a mad position has been discussed. For instance, Richard Ingram (2016) writes that it is

[…] a matter of sense or not to make sense, maybe that’s the question! Or maybe it is a matter of both making sense and not making sense, so that there can be a making sense at times and not making sense at other times, which collectively comprises Mad Studies. In short, could we perform making (non)sense together. (pp. 14-15)

Ingram discusses what counts as science and knowledge and the fact that a knowing emanating from a person with experiences of madness may not count as rational and, therefore, not as knowledge. What Ingram’s statement implies is a production of what Michel Foucault (1980, pp. 81-82) calls “subjugated knowledges,” which can be understood as a set of knowledges that has been disqualified, and therefore not acknowledged as contributing to the understanding of a subject matter.

In exemplifying how a mad reading of games can produce subjugated knowledges, I turn to Dia Lacina’s (2017) discussion of the game Hellblade: Senua’s Sacrifice, a hack-and-slash, puzzle solving and psychiatric horror game. Hellblade: Senua’s Sacrifice is set in the Viking age, where the Pict warrior Senua sets out to save the soul of her lover. In the game, Senua is haunted by voices in her head, hallucinations and flashbacks. The game has been praised by scholars because the developers, Ninja Theory, consulted psychiatrists and people living with mental illness when producing the game (Ferrari et al., 2019). Researchers suggest that this provides a “nuanced” depiction of mental illness (Phelbs, Wagner & Moger, 2020, p. 125) and a “respectful” depiction of psychosis (Fordham & Bell, 2019, p. 5). Yet, Dia Lacina, who identifies as a person with mental illness, critiques the game and suggests that it uses mental illness as an “allegory” and that the game “invalidat[es] the experience of people with mental illness even as it seeks to promote understanding” (2017). Lacina suggests that the game “simply illustrated symptoms society already associates with psychosis” and that “mental illness is more diverse and complicated than experiencing delusions and hallucinations” as represented in the game (2017). Lacina moreover discusses the representations of hallucinations in the game, which function as a guide for the player. They write the following:

I stopped and wondered about how many times in my own life my mental illness has aided me. No intrusive thought has ever saved me from harm or given me direction. Visual hallucinations have only been horrifying or mundane. Flashbacks have never offered profound insight. Perhaps my hyper-vigilance has kept me from danger; it’s also made me lash out at perceived but unrealized threats. (2017)

I propose that Lacina reads the game from a mad perspective and utilizes their experience of hallucinations, flashbacks, and psychosis when discussing the representations in the game. I suggest that Lacina’s discussion forms a counter argument to the above-mentioned researchers’ appraisals of the game. It assists in revealing prevailing stereotypes of mental illness that permeate the game on all levels; in elements such as game mechanics, character design, plots and narratives. This is something that the research overlooks when using psy sciences to discuss the game because they focus on how hallucinations, flashbacks, and hearing voices correspond to diagnostic criteria.

In my view, Lacina’s mad perspective not only become a situatedness -- a position from where games are played and discussed -- but it also becomes a situation where knowledge is produced and a process where experiences of madness are turned into knowledge about games. Lacina’s mad reading of the game, though they do not name it as such, shows that this method is a position from where knowing about games could, recalling Haraway’s (1988, p. 590) words, enable “connections and unexpected openings.” Yet, having said this, we must always remember Merri Lisa Johnson’s (2015) warning not to turn people’s suffering into academic resistance discourse, articulated from a university ivory tower.

Turning this discussion into useful guidelines for conducting a mad reading of games, I suggest that when doing a mad reading of games, one should start by situating oneself. Positioning oneself is not a confession or a disclosure of whether one has been diagnosed with mental illness (or not). It is about creating an awareness of how one arrives at the material and how this affects the scientific pursuit, including material collection, methodology, theorization, and knowledge production. Therefore, I suggest that the following should be reflected upon before investigations start: (1) From what definition of madness do I conduct research? Definitions found within psy science and mad studies are vastly different and produce very different kinds of science. (2) What kind of experience of madness do I have? For instance, do I have personal experience, do I have someone close to me experience madness or do have no experience? Reflecting on this calls for an awareness of the social conditions from where knowledge is produced; (3) How does this experience shape the playing/reading of the game and what knowledge is produced? Do I read from the perspective of madness, or do I take on another’s perspective and read games empathically? Taking another’s perspective means connecting to the experiential knowledge of madness, which can, for instance, be accessed via mad studies. Reflecting on these issues brings us to the next level which is choosing the game.

Choosing a Game

After situating oneself, a mad reading commences by choosing a game to study. Locating madness in relation to the game genre, the company, the place and time of production and its cultural context is essential since madness is relationally constructed and, thus, needs to be located within contexts. To suspend the boundaries of the game -- as suggested by Shaw and Persaud (2020) in their queer reading of games -- runs the risks of shattering the understanding of how madness is contextually produced, but also how madness varies across time and across different games. For instance, a psychiatric horror game produced in the United States creates a very different kind of madness than a visual novel produced in Japan. A platform game from the 1980s produces a very different kind of madness compared to a massive multiplayer online role playing game produced during the 2020s. This also implies that madness can mean different things in different games and in different game genres. Therefore, madness must be considered a temporary and unstable category that only appears as stable in certain game contexts. The realization that madness is not a stable category, ready to be universally applied, sets it apart from research using psy science discourses for analysing mental illness. This also points to the possibilities of what madness can be in, for instance, serious games. It points to the fact that madness does not have to be centred on a diagnosis.


Centring on a game and its context also means playing the game, and this suggests that a mad reading of games is an interactive method. Arguing this, I build on game studies scholars that suggest that textual analysis involves playing the game (Carr, 2019); that it is active engagement with the game (Bohunicky & Milligan, 2019, pp. 51-55) that “include[s] the reader [player] in the analysis of texts” and that considers the players as “thinking as well as acting subjects” (Archibal, 2009, p. 362). More importantly, I draw on scholars that suggest that reading the game as a text while playing, is, in fact, writing the game experience (Bohunicky & Milligan, 2019, pp. 51-55). Consequently, I propose that a mad reading is also a mad playing and a mad experience of the game.

A mad reading of games does not happen after the game is played and when the material is gathered; it takes place during play. This means that the researcher needs to play the game many times. I propose that the researcher should first play in order to experience the game and thereafter play in order to look for how expressions of sanism and/ or madness appear. During play, or shortly after, written or audio field notes should be taken. I suggest that these should be taken each time the game is played, as the game may appear differently depending on how the researcher arrives in the game. Gameplay should also be recorded, since this allows the researcher to go back, watch again and notice aspects of the game that may have been overlooked. Recording gameplay allows for what Diane Carr calls fragmentation, which entails re-watching the game and choosing aspects of the game to be analysed (Carr 2019). In my view, fragmentation allows for further examination of how madness is relationally constructed, and it also offers an opportunity to investigate the normative discourses that produce sanism or madness within the game.

Exploring mad reading further, I will now turn to explaining how such a reading can be carried out. In the sections that follow, I first explain how a mad reading can entail examining the expressions of sanism and following this with a resistance reading. In doing so, I give examples from several games. Thereafter, I turn to explaining how mad reading can entail reading the explicitly mad, focusing on the game Outlast. Lastly, I explore the issue of maddening games and introduce the concept mad leakages while discussing the game Outlast.

Reading and Resisting Sanism

A mad reading of games seeks to identify the workings of normative ableist discourses in texts and how sanism is conflated with other oppressive regimes. The purpose is to interrupt and resist sanism. Investigating representations of sanism is also a good starting point for the exploration of madness. The reason for this is that many representations of madness in games are sanist. This means that madness often appears through the lens of sanism, and sanism is seen through madness in games. However, there isn’t just one kind of sanism in games, which I shall now discuss.

In many games, mental illness is embodied by male characters (cf. Shapiro and Rotter, 2016, p. 1594). This is perhaps no surprise, seeing that men are overall overrepresented in games at large (cf. Taylor & Voorhees, 2018). Male characters with mental illness are often portrayed as violent, psychotic, and homicidal maniacs (Shapiro & Rotter, 2016, p. 1594; Ferrari et al., 2019, p. 6). Violent behaviour is often associated with masculinity in games, but games portray a kind of masculinity where violence is expressed as controlled by an often emotionally stoic character. Male characters with mental illness are often contrasted with this stoic masculinity. For instance, Scarecrow in the action-adventure game Batman: Arkham Knight (Rocksteady Studios, 2015) exhibits erratic, emotional, and unpredictable behaviour, and the patients in Mount Massive Asylum in the first-person survival horror game Outlast (Red Barrells, 2013) are represented as both catatonic and scared or as butchering the staff and raping corpses.

Women, on the other hand, are often represented as victims and/ or patients of psychiatric facilities in games (Shapiro & Rotter, 2016, pp. 1592-1594). These depictions can be connected to the tradition of objectifying women in games and portraying them as passive and/ or damsels in distress. A recent trend in games is to present girls as those dealing with mental illness, such as in platform-adventure game Gris (Nomada Studio, 2018), the platform role-playing video game Child of Light (Ubisoft Montreal, 2014) and the platform video game Celeste (Matt Makes Games, 2018). Representing mental illness using children as a metaphor offers possibilities to highlight the vulnerability of the person suffering from mental illness, but this is problematic due to a long tradition of portraying the relationship between doctors/nurses and mental patients as one of a parent to a child. In addition, China Mills and Brenda Lefrançois shows that the Diagnostic and Statistical Manual (DSM-V), which is a manual that classifies and explains illnesses and behaviours and functions as a handbook for health care services, lists “childishness” and “childlike behaviour” in adults as a symptom of mental illness (Mills & Lefrançois, 2018, p. 512). Furthermore, psychiatric discourse marks people experiencing mental illness as underdeveloped or wrongly developed (Mills & Lefrançois, 2018, p. 504). Representing mental illness as a child or through a child’s perspective unfortunately works to reproduce discourses of mental patients as infantilized.

Sanism also needs to be positioned in relation to issues of race and ethnicity since stereotypes of mental illness are often conflated with stereotypes of race and ethnicity (Rodéhn, 2020). Research shows that there is a history of denoting Jewish and African American groups as predestined for madness, revealing that race, ethnicity, and madness are conflated in cultural representations (Gilman 1985, pp. 24-25, 162). For instance, Blackness has been considered as equal to madness, and blackness became a prerequisite for the social constructions of madness (Pickens, 2019, p. 4). I suggest that this construction of Blackness is the source for why Black men have been portrayed as irrational, unpredictable, and violent in games. An example of this is the pirate lord Vaas Montenegro in the first-person shooter game Far Cry 3 (Ubisoft Montreal, 2012), who is depicted as loud, erratic, sadistic, and violent.

Adrienne Shaw shows that Black and indigenous women are almost non-existent in games, and when portrayed, they are often depicted as abuse victims (Shaw 2014, p. 21). In popular culture, Black women are commonly portrayed as lazy, slow-minded or angry and/or seductive, which are also characteristics used to represent people diagnosed with mental illness (Mollow 2006). The way sanism is intertwined with colonization and racism needs special attention because when sanism is visited on racialized bodies it is especially devastating (Meerai, Abdillahi & Poole, 2016, p. 22). Characterizations of mental illness in video games, where the character is explained as having a diagnosis or illness, occurs more among characters that are white and male. This suggests that white people are represented as suffering from a condition, whereas Black people are merely represented as erratic and violent.

Furthermore, it is common that queer and transgender characters are represented as mentally unstable in games. One example of this is the character Reni Wassulmaier, introduced in action-adventure game Grand Theft Auto: Liberty City Stories (Rock Star Games, 2005) and reappearing in Grand Theft Auto: Vice City Stories (Rock Star Games, 2006). Reni Wassulmaier is portrayed as a prostitute and a porn star. Reni was assigned female at birth, but they go through four gender confirmation surgeries: female-to-male, male-to-female, female-to-male again, and then male-to-female again. This transphobic representation, parodying the process of gender confirmation surgery, works to portray Reni Wassulmaier as mad and as having erratic behaviour -- not being able to decide on a gender. The result of this is that queerness is represented as madness and madness as queerness. The connection between madness and queerness is not new; there is a history of pathologizing and diagnosing transgender people in, for instance, the Diagnostic and Statistic Manual of Mental Disorders. The conflation can also be seen in terms of sexuality. Reni Wassulmaier is characterized as a mad seductress, trying to seduce every man they meet in all different kinds of situations. Shapiro and Rotter show that the appropriation of the mad seductress trope is well-established in media and used as a way to connect feminine and female sexuality to madness (Shapiro & Rotter, 2016). In Grand Theft Auto, the trope is used to portray Reni’s madness and reveal the tendencies to pathologize femininity and feminine sexuality as performed outside the boundaries of heteronormativity.

I suggest that, to expose and resist sanism, the following questions can be useful guidelines to conduct a mad reading of games: (1) What normative discourses produce madness in the game that is being studied, and how are these representations connected to other oppressive ideologies? (2) What kind of madness does the intersection of sanism and other oppressive ideologies produce?

Reading the Explicitly Mad

I suggest that a mad reading of games, drawing on queer reading strategies (Björklund & Lönngren, 2020, p. 197), emphasizes and highlights specific mad characters, themes, tropes, narratives, relationships, and figures that are mad, and it seeks to explore what this can mean. Above I suggest that madness in many cases is represented through the lens of sanism, which means that reading the explicitly mad is also a reading of sanism. To briefly exemplify this, I give an example from the game Outlast, mentioned above. In this first-person survival horror game, you play as journalist Miles Upshur investigating the remote Mount Massive Asylum. Patients have escaped and moved around the hospital killing staff members. At the same time, a ghostly entity, “the walrider,” is also killing staff members and patients alike. In the game, mad people are represented as non-playable characters. They are seen as religious fanatics, catatonic, scared, or as violently butchering staff. They function as props, objects to create scares or to enhance the feeling of unease. Mad people are depicted as naked and skinny or appear monster- or zombie-like; sometimes they are covered in blood. They are situated in the dark, maze-like, ransacked hospital. The asylum is further staged by haunting music and flickering lights or night vision scenes. Furthermore, patients are solely seen through the perspective of the player. In this game, madness appears as fear, trauma, violence, and confusion.

A mad reading highlights how and where madness appears in the game. It assists in describing and analyzing the relationships and contexts where the explicitly mad are made visible. A mad reading does not try to diagnose characters or look for how diagnosis appears within the game. This sets mad reading apart from previous research, where researchers seek to identify mental illness in games. For example, researchers have looked for autism (Gibbons, 2015), psychosis (Fordham & Ball, 2019: 2), schizophrenia, paranoia (Ferrari et al., 2019, pp. 3-5, Anderson, 2019, p. 22), bipolar condition, and depression (Shapiro & Rotter, 2016, p. 1) in games. I suggest that researchers use diagnostic labels to investigate representations of mental illness because, as Dunlap writes, “[i]dentifying and analyzing mental illness representations in games is uniquely challenging” (Dunlap, 2019, p. 80). Arguing this, she suggests that, unlike gender or race, mental illness is not manifested by visible signs of the body and is therefore difficult to detect in games (Dunlap, 2019, p. 80). The use of diagnostic labels is therefore applied to characters’ behaviours. This kind of research, drawing on Ledder (2019, p. 36), is an expression of ableism where mental illness has to signify something -- it needs to be marked out as something -- rather than just existing.

A mad reading allows for madness to just exist, and it explores this existence. This approach to games asks the questions, what is madness, and what can madness be in games? In contrast to previous research, madness is not predetermined, and it is not a diagnosis to be looked for or found in the game. I propose that madness is something that is being done within the game and that madness is relationships, actions, and interactions. The game Outlast helps exemplify this: here madness appears in relation to the genre (horror), the narrative (navigate through a psychiatric hospital with escaped patients), the sound (eerie music), the design (gothic haunted hospital in sepia and grey colours), and game mechanics (first-person shooter and stealth gameplay mechanics). Madness is also produced as a relational situation between patients, between patients and staff members, as well as between the player and the patient.

The focus on the relationality of madness reveals how madness appears but, more importantly, how it may differ from game to game as well as within a game. This means that a character is mad only as far as it is placed in a context and in a relational situation. Equating madness solely with diagnosis, as seen in previous research, or looking for how characters exhibit mental illness is a limiting approach. In contrast, a contextual and relational approach avails an open-ended investigation providing a more nuanced understanding of the explicitly mad and what it can mean in games.

Maddening Games and Mad Leakage

Building on queer reading practices (Björklund & Lönngren, 2020, p. 197; Shaw & Persaud, 2020), I suggest that a mad reading of games works with the tension between what is visible and what remains invisible in games. A mad reading recognizes that the hidden is equally important as the visible for what is considered a “correct” reading. This kind of approach builds on queer reading, which entails “reading across different paths and histories in search for obscure(d) connections” (Gerdén, 2018, p. 168). Searching for connections and other possibilities reveals the “limitations of the official, the traditional, and the normative” (Mejeur, 2018, p. 130) and offers ways to “complicate limited and problematic representations and find in them complex, meaningful contributions” (Mejeur, 2018, p. 118). Madness can indeed mean violence, chaos, irrationality, confusion, or distress, which is often seen in sanist representations. Yet, these problematic representations can open up new understandings and perspectives on madness.

Building on this, I propose that mad reading is a performance; it is an active undertaking with and for the game where the researcher searches for different meanings beyond the traditional, correct or officially sanctioned version of the game. Reading games madly is therefore, to use Wolframe’s (2014, 143) terminology, a maddening of the game. Maddening is similar to cripping, which entails exposing the ways in which ableism “get[s] naturalized and the ways that bodies, minds, and impairments that should be at the absolute center of a space or issue or discussion get purged from that space or issue or discussion” (McRuer, 2019, p. 135). I propose that a maddening of games places madness back in the centre of investigation. It questions whose story and experience is centred when playing the game and attempts to highlight that every story has madness within.

To apply these ideas, I return to the game Outlast and attempt to read it beyond sanist representations and beyond the limitations of the official narrative. In this new narrative, what journalist Miles Upshur (and, consequently, the player) witnesses when stepping into Mount Massive Asylum is the event of a mad liberation. The patients at the asylum have staged a revolt against the oppressive psychiatric system. Due to the mistreatment in the hospital and the fact that staff members have subjected patients to questionable treatments, experiments, and torture, an uprising has taken place. It is a rebellion against ableism. Armed men have tried to quell the revolt with violence, but the patients have armed themselves with what was available and subsequently killed the men. The variants, the patients that have been especially ill-treated by the psychiatric system, were particularly violent. In different ways, the patients try to communicate the reasons for the mad liberation to the player (journalist Miles Upshur), but this is often misunderstood by the player, who fights them off or runs away. By slowing down the play and interacting with the patients, it is possible to resist sanism as expressed in the game’s mechanics and visual design. A slower play can therefore bring other stories out and assist in maddening the game. As argued above, playing is reading the game, and reading is playing the game. A mad reading thus calls for a different kind of play.

Maddening Outlast allows me to find the cracks where the ableist and sanist story leaks madness. Seeking out these cracks permits madness to overflow into the experience of the game and the game play. In suggesting this, I build on queer theorist Tiina Rosenberg’s (2002, pp. 117-120) argument that all kinds of cultural productions that appear heteronormative have cracks where queerness seeps out, and she calls this “queer leakage” (queert läckage). Drawing on Rosenberg, I suggest that all games have cracks where madness seeps out, and I call this “mad leakage.”

One example of mad leakage in the game Outlast can be found in the patients’ actions. What first appear as sanist representations of catatonic patients are, in fact, a crack where madness seeps out. In the game, some patients can be seen sitting passively on sofas, thinking. They can be read as the leaders of the revolution. Quietly contemplating the situation, they are planning the next steps in the revolt. The patients have no intention of leaving the hospital and plan to make the asylum their home now that the staff is gone. They object to ableist society outside the hospital. Their choice to remain in the hospital is a resistance against a society where they are expected to get better and become productive subjects in the neo-liberal economy. Furthermore, they seek to resist a society where they are measured in terms of how active and useful they are. In this reading madness can mean liberation.

Moving beyond Outlast and discussing mad leakage on a more general level, I suggest that the approach can further reveal that madness is not only illness -- it can mean many other things, such as excellence and creativity (as seen for instance in LeFrançois, Menzies & Reaume [2013] definition of madness). This opens up the possibility to read any character expressing creativity and excellence as mad. Madness can also be the ordinary and mundane, which means that madness can appear everywhere. This moves beyond able-minded logics and has the purpose to subvert the mad/sane binary. It furthermore opens up for other possible meanings to be apply to madness and mad people.

Furthermore, paying attention to mad leakages in games in general allows for a recognition that madness does not only appear through character design. For instance, Ferrari et al. show that mental illness is also represented in the game setting, game ambience, and game goals (2019, pp. 5-6). Building on this, I suggest that goals, plots, themes, aesthetics, narratives, language, game design, game mechanics, dialogues, and/or sounds can also be representations of madness. This avails an opportunity to further unhinge madness from characters and their traits and consequently from diagnostic labels and criteria. Furthermore, paying attention to where games leak madness implies finding in the game what madness can mean. This is a completely different investigation than one that beforehand decides on what madness is and seeks to look for this in the game. Thus, a mad studies approach to games can be considered as a doing -- a performance -- that alters the way that the game is played, experienced, and discussed in research. This kind of research implies transgressing the boundaries that psy sciences set up for what madness can mean and become in, and through, games.

I suggest that the following questions can function as useful guidelines for conducting mad readings of games: (1) What is madness in terms of this particular game? (2) Does it appear in a character, a landscape, game mechanics, a relationship, or something else? In other words, what and where are the cracks where madness seep out? (3) How can this leakage be understood and how does this transform our understanding of madness?


In this paper I have outlined a mad studies and mad reading of games, which provides a departure from psy science-influenced research on games. Mad studies allows for an open definition of madness, not limited to diagnoses and psychiatric labels. Instead, mad studies asks the researcher to focus on the situations and relationalities where madness appears in games and acknowledge that it can appear differently depending on the game and the relationships within the game. A mad reading of games is also suggested to be a situation where new and potentially different knowledge of games can be produced. It deconstructs and resists oppressive regimes but also opens up new possibilities for understanding madness -- not only in games, but in society at large.



I would like to thank my colleagues at the Centre for Gender Research at Uppsala University and the anonymous reviewers for valuable comments on previous versions of this paper.



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