Michie Leccese, a doctoral candidate at USC Annenberg School for Communications and Journalism, found herself in a challenging period. She was grappling with personal grief after the sudden loss of a very close loved one. Leccese had envisioned growing up with this close friend, sharing experiences, being there for each other for eternity. Yet, here she was, alone and sad. The finality of death was too hard to accept or comprehend.

Leccese was overcome with sadness. Seeking solace, she turned to The Legend of Zelda — Majora's Mask, a video game.

"Playing it helped me process my own grief, and I've revisited it during times of transition," she said. Majora's Mask explores themes of loss and grief, mirroring the five stages proposed by Swiss-American psychiatrist Elisabeth Kübler-Ross, who was a pioneer in near-death studies — denial, anger, bargaining, depression, and acceptance.

Leccese hopes that her doctoral research, focusing on the intersection of interactive media and its therapeutic benefits, will offer insights to others who may experience similar low points in life.

Players traverse the stages of grief through the game's protagonist, who initially denies the looming crisis, then confronts anger towards the antagonist. He then helps others through grief and despair, engaging in bargaining, and facing moments of depression. Ultimately, aiding others brings him acceptance, offering players a message of hope amid adversity.

The therapeutic potential of video games lies in some games' ability to provide an immersive and engaging platform for individuals to explore and navigate complex emotional landscapes. Through gaming, researchers say individuals can face and process emotions in a safe, controlled environment, promoting introspection and personal growth. The interactive nature of gaming may allow for tailored interventions that cater to each individual's unique needs and preferences.

In 2022, according to The U.S. Department of Health and Human Services, almost one in four adults, or 23.1% of the population, had some form of mental illness. Many of those affected lack the necessary support systems or financial means to pursue conventional therapy.

Video games, when designed to deliver therapeutic benefits, may offer the possibility of a cost-effective alternative, according to the National Institute if Health. In fact, The National Institute of Health’s research concluded that videogame play has the potential to enhance life satisfaction and improve mental well-being aspects of Positive Emotion, Engagement, Relationships, Meaning and Accomplishment — collectively referred to as PERMA by clinical researchers.

The National Institute of Health's research on the therapeutic potential of gaming in fostering pro-social behavior and providing social support networks is particularly relevant during times like the COVID-19 pandemic.

Video game genres and their impact on mental health

Computer video games — CVGs

Broadly, Computer Video Games (or CVGs) encompass all types of video games played on computers or gaming consoles. This includes a wide range of games, from action and adventure titles to simulation and strategy games. CVGs have evolved significantly over the years, from simple 2D games to complex, immersive experiences with high-definition graphics and advanced gameplay mechanics. Within this extensive gaming landscape though, several subgenres may have potential in different types of therapies.

Adventure video games — AVGs

Adventure video games (or AVGs) are a genre where players assume the role of a protagonist in a narrative-driven story, typically involving exploration, puzzle-solving, and interaction with characters and the game world. These games often prioritize storytelling, character development, and immersive environments over action-packed gameplay. Adventure games can be further categorized into subgenres such as point-and-click adventures, action-adventures, text adventures, and graphic adventures. Some well-known examples include the "Legend of Zelda" series, "The Witcher," and "Life is Strange."

Roleplaying game video — RPGs

In some ways a little more intense, Roleplaing games (or RPGs) are a genre where players assume the roles of characters within a fictional setting. RPGs typically involve immersive storytelling, character development, and decision-making that can influence the outcome of the game. Players often control a single character or a group of characters, progressing through a narrative while completing quests, exploring worlds, and engaging in combat or other challenges. RPGs offer players the opportunity to immerse themselves in richly detailed worlds, shape the story through their actions, and develop their characters in unique ways, making them a popular and diverse genre within the gaming industry.

Tailored game solutions — addressing mental health challenges with precision in games

Ongoing research into games as therapy includes immersive virtual reality experiences that aid exposure therapy for conditions like ADHD and autism.

With advances in video game technology as well as mental health research, games are being created that are focused on specific mental health ailments such as post-traumatic stress disorder (PTSD), anxiety, depression and neuro-divergence.

USC neuropsychologist Albert Rizzo has created Bravemind, a VR exposure therapy simulation for PTSD. Rizzo, who directs the medical VR lab at the USC Institute for Creative Technologies, says Bravemind has now evolved into a comprehensive tool for training resilience, known as Strive.

Training resilience in military video games refers to simulating and reinforcing mental toughness, adaptability, and perseverance in the face of challenges or setbacks. It exposes players to combat scenarios, stress, and failure, fostering focus and determination.

Rizzo said Strive aids in preparing individuals for combat zones. Its simulated readiness measures are designed to mitigate trauma, offering a beacon of hope for those facing such challenges.

Simulated readiness measures often include training with features like realistic combat simulations, demanding missions, and consequences for failure, all of which aim to build players' resilience by pushing them to stay composed, think strategically, and persist despite adversity. Through repeated exposure to challenging scenarios, players can develop resilience skills that may have real-world applicability, such as in military or other high-pressure environments.

Rizzo said clinical studies he;s conducted have shown promise “We predicted that people with co-morbid depression, which is common with people with PTSD, that they would have a better outcome with VR exposure to be more emotionally active. When people are depressed, its hard to engage in trauma focused therapy, and we found better outcomes in that population using VR to be clinically statistically significant. We can recommend that the VR approach with confidence that it may produce better outcome,” he said.

The evolution of games such as Bravemind into Strive underscores the intersection of technology and mental health, to address the challenges faced by individuals in high-stress environments utilizing exposure therapy techniques.

Exposure Therapy is “helping a patient to go back and confront and reprocess difficult emotional memories, but at a pace they can handle," said Rizzo. "The patient closes their eyes, imagines the trauma, and narrates the experience as if it's happening right then in the therapy office."

“If they get a successful treatment outcome once treatment is concluded, they're better prepared to deal with things that have held them back in everyday life and they continue to improve as they no longer avoid things that evoke memories even though they have know they pose no threat, they still evoke memories or trigger stimuli,” Rizzo said.

"The aim of Strive is to engender the same level of engagement found in video games while promoting health and well-being," said Rizzo, drawing parallels to his work in developing game-based physical therapy and cognitive assessment tools.

Rizzo emphasizes that Strive is not merely a game but rather a treatment and training tool. This training is supposed to cultivate skills applicable in high-pressure environments beyond gaming.

Rizzo said this is just what some patients seem to get from the treatment and he is delighted when they tell their stories. “I hear stories from patients and some of them say 'this changed me,’ Rizzo said. “When we first got funded for this work, I told the Program Manager at the Office of Naval Research that if we fix ten people, that will pay back all the funding put into development of these systems. How do you put a measure on reducing human suffering. When people are relieved of PTSD, they are more productive, society benefits, they have lower healthcare needs later in life because PTSD can cause other medical conditions as well,” he said.

Funding such projects can be very challenging. “I see these wins as just as important as the large scale randomized controlled trials. When we come accross people that have these benefits, you can really feel like you changed 16 years of life that could have been filled with suffering and made it much better for that person. That is a very fullfilling experience to have, and it makes all the hardwork and frustration of trying to raise money to build these as its very challenging, it makes it all worthwhile," Rizzo said.

This idea of using games for therapy also appears to fit well with today's tech-savvy generation of “digital natives” who have grown up with them.

In fact, the field of therapy has evolved to include a specialized category known as "Geek Therapists." These professionals are clinically licensed psychologists who have honed their expertise in what they call 'Geek Therapy.' This innovative approach integrates elements of geek culture such as video games, anime, comic books, and more into therapeutic processes. By incorporating these familiar and beloved cultural elements, Geek Therapists create a unique space where clients can explore their emotions, confront challenges, and develop problem-solving skills in a way that feels natural and engaging. This approach not only helps clients feel understood and accepted but also taps into their passions and interests to promote personal growth and well-being. Geek Therapists often utilize this approach to address a variety of mental health concerns including anxiety, depression, social skills development, and self-esteem issues, offering a refreshing and effective alternative in the realm of psychological therapy.

How games help with certain mental conditions, part 1

The power of story telling

One of the more compelling aspects of incorporating video games into therapy is the ability to leverage the power of storytelling. The games can feature rich narratives and persuasive characters whose experiences resonate with players on a profoundly emotional level. By immersing themselves in these virtual worlds, individuals can supposedly develop empathy and insight into their struggles, finding solace and validation in the journeys of fictional characters.

"In that aspect, narrative-style games have a throughline where one can have progress or moral choices in your progress line. Being able to decide on a choice will change how the game interacts with you," Leccese said.

"By examining character experiences in media, individuals can gain insights into their traumas and coping mechanisms. While the concept is not new, ongoing research continues to explore its effectiveness," Leccese said.

Narrative-driven games like Life is Strange, are seen as therapeutic tools that may allow individuals to engage with their emotions and experiences in a supportive virtual environment.

"Life is Strange aids individuals in processing grief and trauma through narrative responses," Leccese said. The game explores mental health issues through the struggles of its characters — The antagonist is a psychopath, several characters deal with bipolar disorder, schizophrenia, social anxiety and developmental disabilities like ADHD, High Functioning Autism, or Asperger Syndrome.

How games help with certain mental conditions, part 2

A narrative response in video games typically refers to how the story unfolds based on the player's actions and decisions. Unlike linear narratives where the story progresses in a predetermined way, narrative response games offer branching storylines or multiple endings based on the choices players make throughout the game.

In these games, players often have agency to shape the story through their decisions, interactions with characters, and the consequences of their actions. The narrative response can vary from subtle changes in dialogue or character relationships to significant plot twists and divergent story arcs. Games like The Witcher series, Mass Effect, and Life is Strange are examples of narrative response.

Another sub genre of video games are “platformers,” action games where the player controls an avatar that jumps and climbs between platforms or other obstacles in real time. The player must use their skills to avoid falling off platforms or missing jumps. Platformers often feature uneven terrain, suspended platforms, and two-dimensional graphics.

"A major aspect of video games is the idea that you can try and fail and try again while systematically getting better in a safe environment. Consider games like Mario platformers," Leccese said. "You might encounter a pesky bug that derails your progress, forcing you to restart. Yet, in this virtual realm, failure is natural—it offers individuals the opportunity to experiment."

In the real world, failure may often carry a stigma. Yet, it's an essential aspect of growth and learning. Understanding that failure is not the end but a chance to try anew, armed with newfound knowledge, may be empowering to some patients.

With so many games, types of games and subgenres out there, selecting one often comes down to personal preferences. Gender may influence the choice between single-player and multiplayer experiences, as some women may gravitate toward single-player games due to their discomfort with the toxicity sometimes present in online multiplayer environments.

How games help with certain mental conditions, part 3

According to Safe In Our World, a non-profit that promotes mental health awareness, the game helps improve mental health by making players consider how they deal with certain situations in their own lives. The game features characters who experience real trauma, such as the death of a daughter, and the game doesn't shy away from showing how these events impact the characters — a father's panic attacks are connected to the deaths of his daughter and son, and how these events impact his confidence in keeping others in his life safe.

What features of video games resonate with players? "The practice of success after failures, accessibility features, and narrative-driven games with moral choices that enhance therapeutic experiences — all play a crucial role in engaging a broader audience," said Soraya Murray, a professor and visual studies scholar at UC Santa Cruz, who teaches history, theory, and critical game studies. Games with accessibility features that connect with individuals who have disabilities, such as Cult of the Lambs, include dyslexic fonts.

"With accessibility features, a player can change all the fonts in the game to be dyslexic-friendly, making reading subtitles and menus of various types less challenging," said Leccese.

Stardew Valley is what the industry calls an independent video game, one created by individual developers. It puts 1 to 8 players in charge of running a farm, including growing crops and raising livestock; and Animal Crossing, a game to create a home, interacts with cute animal villagers.

"These games recreate certain situations that might trigger soldiers, allowing them to experience them in a safe and controlled environment. This helps them learn to manage their emotional reactions to those events," said Murray.

Furthermore, Murray suggests that video games can serve as simulations for behavioral training, helping individuals to confront and manage traumatic memories. "Video games can be experienced in a simulation which can be used as a kind of behavioral training... [they] can help remember a person's memory of a traumatic event and use constructive ways until they can control their response to that memory."

Is traditional therapy going to be a thing of the past?

With all the promising therapeutic benefits that video games provide, can they replace traditional therapy? Leccese and Murray emphasized that gaming should be seen as an adjunct to therapy rather than a replacement.

"For instance, for someone with social anxiety, multiplayer games might be beneficial, but without therapeutic guidance, they might struggle to effectively use the platform for social connection,” Leccese cautions. “Small groups can serve as a stepping stone to online interaction, but clinician guidance is crucial."

There are games that are more tailored to serious purposes, and that require government regulation, such as the FDA-approved video game for ADHD called EndeavorRX. The game is designed for kids aged six through 12, and it requires a prescription. However, even with such games, it's essential to work with doctors and clinicians. These games are specifically crafted for mental health purposes, which is not currently the focus of most commercial games.

Location map of a sample of centers providing therapy through video games

Player spotlight

As a child, Mathis Delestre said he navigated the world with a quiet apprehension, his reserved nature casting a shadow over his interactions.

"I was a shy kid, often overwhelmed and anxious in social settings," he reminisced. "I often found solace in solitude, retreating to the safety of my room where the world felt less daunting."

Mathis Delestre, an Annenberg student, describes how video games have helped him overcome his shyness.

Delestre said his reluctance to engage with others due to his anxiety was a barrier that seemed insurmountable. In a landscape where social bonds are the currency of childhood, Delestre's shyness was a roadblock to forming friendships.

"Initially, I was drawn to the games for their novelty and fun, but the real significant impact on me was the communal aspect. Video games gave me a community of similarly interested people to engage and share experiences, providing therapeutic relief," he shared.

For Delestre, video games served as more than just a form of entertainment—they became a catalyst for personal growth. He left his home in France and is now a student at the University of Southern California, where he serves as an Esports Journalist and Editor at USC’s Annenberg Media, roles demanding confidence and strong interpersonal skills. Emphasizing the therapeutic value of gaming, Delestre attributed his newfound sociability and resilience to these virtual realms, highlighting their role in combating his former shyness and preventing loneliness.

Delestre now prefers multiplayer indie games as they provide him with a community, like Stardew Valley and Slay the Spire, a game that follows the story of mysterious outcasts who climb the Spire to destroy its evil influence. These games let him take charge, make him more outgoing, and success minded

However, despite all the advances with therapeutic video games, Murray cautioned against solely relying on games for therapy. "I don't think that games just without intervention can necessarily stand in for a therapist. I think that would probably be very ill advised actually." Murray cautioned.

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