In college, I studied English and psychology, a hybrid degree. My capstone project focused on analyzing the portrayal of mental illness (or, more often and regrettably, “madness” or “insanity”) in roleplaying games. It wound up more of a survey than a statement, beyond pointing out some obviously flawed approaches that I will bring up again here. It’s been less than two years since I finished that project, but I feel my understanding of the medium of RPGs and the world of mental health both grow every day.
First, I should differentiate some terms. I use “stress” to mean tension brought on by circumstances. For example, knowing a killer alien is hunting you is likely to put you on edge. “Trauma” begins to get into a space where one ought to tread carefully, so I’m going to outsource my definition. SAMHSA says: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.”
More contentious yet is finding a definition for mental illness, or mental health. Even establishing how those two concepts are related can be tricky. To that end, the CDC says “poor mental health and mental illness are not the same. A person can experience poor mental health and not be diagnosed with a mental illness. Likewise, a person diagnosed with a mental illness can experience periods of physical, mental, and social well-being.”
Personally, I don’t believe in arbitrarily saying certain people’s minds are fundamentally “ill” just because they deviate from societal norms and expectations. That is a judgment which is inconsistent from person to person and cultural group to cultural group, and which has been used in countless harmful ways throughout history. This is what trips up even the RPGs that otherwise do a pretty good job, I think. More on this later.
In the interest of having a working definition, I will say that mental health refers to how well one’s mental and emotional paradigms match the expectations of the society they inhabit. Therefore, mental illness can be seen as paradigms that deviate from those expectations to the point that existence in that society becomes challenging.
Let me bring this back to RPGs with an example of where I’m headed with this essay. The first time I played The End of the World, a game in which you play as yourself in the context of an apocalyptic scenario, it was with university classmates. This was for a class assignment, as a matter of fact; I didn’t really know any of my fellow players outside of class.
The game began as is typical for EOTW: we (our in-game selves, much as their real counterparts) were sitting in an on-campus dining hall when concerning, sporadic news reports began to filter in. Pretty soon, zombies attacked us. We escaped narrowly to someone’s dorm room and began to plan our next steps. It was at this point that I (the player) began to consider what I’d really do in this circumstance, having just dodged a grisly death by a hair’s breadth. I decided I’d call my dad. I had to know if he was safe, and if so, seek his advice on what to do next.
As soon as I relayed this to the GM, I realized the awkwardness of my choices. This guy barely knew me, and I was asking him to roleplay as my father (who he knew nothing about) in a fairly intimate conversation. It was a non-starter, and also took pretty much everyone out of the game until I decided to just resolve the outcome of the call myself and move back to the action.
I bring this anecdote
up not just for its cringeworthy humor, but because it represents an aspect of
roleplay that has always mattered to me: I want my characters, be they copies
of myself or something much more fanciful, to react in believable, human ways. One
way that manifests is a desire for trauma to have meaning in the game.
End of the World: Zombie Apocalypse (2014, Fantasy Flight Games)
Let’s move on to another game example. Imagine a first-time D&D player showing up with their debut character: a high elf wizard with the noble background. Level 1, fresh from her mansion, with only a theoretical curiosity for the arcane and a yearning for adventure in her head. Let’s say this character is running through the 5th edition starter adventure, Lost Mine of Phandelver.
The adventure starts with an ambush by goblins on the road. Just four goblins versus the party of adventurers; simple enough. This fight can be pretty brutal if the GM plays their cards right, though; the goblins can employ some pretty scary hit and run tactics with their Nimble Escape feature. In this playthrough, maybe none of the PCs die, but our wizard gets hit by a couple of lucky arrows and drops. The cleric saves her with a Healing Word, but she comes to with the knowledge that she almost died.
Personally, I would imagine this fledgling mage would feel pretty freaked out. I don’t think it’s a stretch that a brush with death would be traumatic for someone coming from a life of pampered luxury. However, D&D has absolutely no game mechanics to support this line of roleplay. I can decide she sticks behind the paladin from now on, or learns more defensive spells as she levels up, but as far as the game is concerned, I have no reason to act like that. My hit points are back to full from a single spell or an hour of downtime; let’s get back to the killing – I mean, the adventure!
To that end, the same logic applies to the reverse: maybe my elf got some good attack rolls in and killed three of the goblins herself. Goblins are unambiguously sentient people with their own society and culture by D&D’s official lore (as well as how they’re presented in Lost Mine). What if my elf feels remorse or disgust at her actions? In this case, it would actively detract from the game experience. This is because D&D is a violent power fantasy above all else.
Not to go on too much of a tangent here, but D&D (in its current iteration’s base rules) allows characters to improve through violence and nothing else. What’s more, the improvements they earn are almost exclusively pertinent to killing and avoiding being killed. This isn’t necessarily to knock that style of game, although I don’t personally prefer it.
But this is the reason D&D doesn’t model trauma, especially the mundane (as opposed to magically inflicted) kind. If my wizard gets more and more distraught over her bloodshed as the adventure continues, and the adventure is 80-90% about killing more thinking beings, sooner or later I will have to roleplay a breakdown, a sadistic change of heart, or a tearful departure before bringing in my next character.
This flavor of escapism doesn’t work if you look too hard at the consequences of your actions, even on your own character. There’s plenty of deconstructions of this in the hobby, such as John Tynes’ Power Kill, which frames the characters as psychiatric inpatients who have gone rampaging, thinking they’re murderous adventurers.
As a last note on D&D, early editions had explicit rules for characters being afflicted with real-life illnesses such as schizophrenia, albeit gamified in a way that bears almost no resemblance to the experience of those with the actual diagnosis, and far more to harmful, sensationalized depictions from other works of fiction. This was clearly an afterthought in the 70s and 80s, and is even more so now, with the 5e Dungeon Master’s Guide retaining slightly smoothed versions of these effects without the real-life name (because we can’t be insensitive, now can we?)
Dungeons & Dragons 5th Edition: Lost Mine of Phandelver (2014, Wizards of the Coast)
Let’s move on, then, to a game that actually wants to explore these things. Call of Cthulhu is no power fantasy. You are set up to play as ordinary people, and in some ways, CoC investigators are actually feebler than your average joe. One of these ways would certainly be their sanity. In CoC, sanity is a meter that starts at a certain value and only goes down. Once it’s empty, your character is “permanently insane” and you can no longer control their actions at all.
This deprivation of player agency is at the core of CoC’s sanity system. Whenever you go insane, be it “temporarily,” “indefinitely,” or, as mentioned above, “permanently,” the manifestation of this debility in the game is determined randomly, unless the GM wants to fudge it and pick an entry from the tables in the book.
The way this works is not only horrendously inaccurate to any kind of real mental illness or response to trauma, it’s so swingy that it’s often not even a fun gameplay experience. Yet another example: I recently ran a prewritten scenario from the 80s, One in Darkness. The investigation was a little slow at first, maybe, but heading swiftly to an interesting climax when the central monster first reared its head to the whole party.
Despite being depicted in the art as a giant, demonic rat, this was an avatar of the god Nyarlathotep, and so simply witnessing it cost the characters either 1d10 or 1d100 sanity points (SAN), depending on if they made a singular roll. That meant losing an average of 5 SAN and going temporarily insane if you failed another roll, or an average of 50 SAN, which for many characters means permanent insanity and automatic loss of your character.
Here's how it played out: I had the avatar pop out of a sewer grate while the PCs were driving to an NPC’s home. They were split across two cars. In one car, all three PCs went permanently or indefinitely insane. They crashed into the avatar (who, as a kicker, was immune to harm from nonmagical objects) and all died because the driver’s madness manifested as, essentially, road rage. The other car’s driver was also properly insane and drove into a house while her passenger fainted from temporary insanity. Those two survived until the cops showed up, but obviously that was the end of the adventure. The avatar simply walked away.
Obviously, reducing the numbers on the SAN loss would mitigate some of that fiasco, but I still feel that CoC is regularly hamstrung by the simultaneously rigid and chaotic way its characters react to trauma. This is to say nothing of the way it takes a sampling of real-life symptoms and diagnoses and attaches them to game mechanics completely haphazardly.
One more example of the disservice CoC does to this subject is in one of the very few ways you can regain SAN. Investigators who successfully unravel a mystery, protecting innocents and apprehending no-goodniks in the process, regain a die or two of SAN. This has the implication of moralizing the game’s attempt at portraying mental illness. You might stop being crazy if you’re a good Samaritan – because that’s how mental health and trauma work, right?
Call of Cthulhu 7th Edition Core Rulebook (2014, Chaosium, Inc.)
The next game I want to touch on is Free League’s Alien RPG. This system chooses a broader, perhaps more generic “stress” mechanic; every time your character experiences something stressful or traumatic, or pushes themselves hard, they get stress dice. Stress dice can make you more effective, but they can also make you panic. This creates a neat little flow in which you start reacting effectively to the dangers that surround you, right up until you’re so freaked out that every little thing you have to do is almost guaranteed to cause a meltdown or overreaction.
I feel this captures the Alien movies quite well, and also seems a decent way to represent how competent people would fold under such distressing circumstances. I also don’t feel that it would be fair to criticize the game for its avoidance of the subject of real mental illness or the more nuanced effects of trauma. This is because the scope of the Alien RPG is focused on the encounters with the titular creatures, not on deeper character interiority. The character sheet is simple and focused on telling you what you’re good at when it comes to space exploration; Alien PCs are meant to die far more than change and grow.
I would contrast that with D&D because that game claims to have three “pillars” of gameplay, all equally important, and roleplay is one of them. 5e D&D also tries to do it all, with some mechanics included to flesh out your character’s personality. Alien is up front about its intent to terrify and maul your character, and its ruleset supports that.
Alien RPG Core Rulebook (2019, Free League Publishing)
Lastly, let’s look at Unknown Armies, a game I love, and the one that gets closest to my ideal for handling this subject. It actually has a lot of similarities to Call of Cthulhu: eminently mortal characters, similar dice mechanics, a focus on what skills your character is and isn’t good, and of course, a system for modeling trauma.
The first thing UA does better than CoC is splitting “sanity” into five “shock gauges.” These are categorized as Helplessness, Self, Isolation, Violence, and the Unnatural: the kinds of trauma you might encounter in UA’s occult underground. I might monkey with this division a little (maaaybe combine Helplessness and Isolation?), but on the whole I don’t feel it needs adjustment; it works well.
The next refinement: a shock gauge doesn’t just decrement when you are subjected to a relevant traumatic event. Rather, you either get a hardened or failed notch. The former means you become more resilient to the trauma, but also develop a more detached or warped relationship to that category. The latter means you are more frightened and shaken for future encounters, and in the moment, you fight, flee, or freeze. Notably, the player chooses which of these happens to their character, not the GM.
I find that this is a much more believable model, and also lends itself to thinking about who your character is and how their traumas change them. Characters are actually expected to begin with some notches, allowing you to be someone used to killing others (by adding hardened notches to your Violence gauge) if you want to be that kind of murderhobo. There are tons of other ways you could assign notches, though, and this leads to some really interesting characterization through the lens of trauma.
Where I feel UA drops the ball is what happens when you gauges fill up, specifically the failed notches. This is where the game brings in real-world symptoms, and under the category of “ongoing madness,” no less. The game allows players to “work with [their] GM” to figure out the specifics (unlike CoC), but you’re choosing from a list including flashbacks, substance addiction, and so on. I do appreciate the designers’ conscious choice to leave out dissociative identity disorder and schizophrenia (they include a half-page explanation on why they felt this would be going too far), but I feel that if one or two diagnoses are better off left alone, you should really question what is so different about the rest that makes it okay to include them (and, again, label them “madness.”)
Unknown Armies 3rd Edition, Book 1: Play (2016, Atlas Games)
Okay. This has gone quite long. Let’s end on some takeaways that I want to keep in mind as I think about how I would create a system for stress, trauma, and/or mental illness in a game of my own. First, I am not really interested in designing a power fantasy, and I am interested in exploring these topics intelligently and compassionately. This means I will want to at least acknowledge them in my thinking about the design, if not include mechanics on them.
Second, I do think mechanics would be wise. My reason for saying this is that mechanics are how we engage with all aspects of a game. When you don’t address something you claim is important through a mechanical lens, it won’t end up being important at a lot of tables (see my comments about roleplay in D&D 5e – and this applies for the exploration pillar, as well.)
Third, there has to be nuance. A 1-100 meter isn’t going to cut it for such a deeply nuanced subject. Fourth, as we learned from Alien, it has to be in line with the overall scope of the game. Fifth, player agency must be preserved.
Sixth, avoid disrespecting the real lived experience of people who have undergone trauma (which to some degree is basically everyone) and who live with mental illness. This would include not calling people “mad” or “insane” for struggling with addiction, for example. This one is definitely easy to screw up, but it’s also very important. Research, sensitivity readers, and so on are key.
And lastly, seventh, is the point I’m still chewing on: how do you represent real mental illness in a game, if that’s something you decide you want to do? I’ve established that it has to be incorporated into the mechanics, at least to some degree. But any attempt to attach real symptoms to mechanics that I’ve seen has not looked good in practice.
Maybe separating trauma from diagnosable mental illnesses is a place to start. After all, the idea that you can develop schizophrenia from seeing a spooky fish-man has always been a laughable flaw of Call of Cthulhu. If you didn’t know, you can’t just “become schizophrenic” at the drop of a hat. That’s not how the illness works.
I still need time to think on that one, so I’ll come back to it later. This is a 3,000 word monstrosity as it is. I’ll sum all this up by saying that whether you’re writing or running an RPG, you should give at least some thought to the depiction of trauma and mental illness, because it’s probably in there somewhere, and if it’s a focus area for that game, don’t make an ass out of yourself by doing the subject injustice.
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