An Emergency Call

The Mental Health of Teenagers in Two Novels
and a Video Game

Una llamada de emergencia

La salud mental de adolescentes en dos novelas y un videojuego

Juan Carlos Saravia Vargas

Escuela de Lenguas Modernas

Universidad de Costa Rica, Costa Rica

José Roberto Saravia Vargas

Escuela de Lenguas Modernas

Universidad de Costa Rica, Costa Rica

Adriana Ramírez Guerrero

Escuela de Lenguas Modernas

Universidad de Costa Rica, Costa Rica

Byron Ramos López

Escuela de Lenguas Modernas

Universidad de Costa Rica, Costa Rica

Abstract

This article compares and contrasts two novels and video games where the participation of teenage characters who battle against mental illnesses becomes fundamental to support the narrative of the text. The objective is to analyze the representation of clinical depression in Vizzini’s It’s Kind of a Funny Story, the depiction of obsessive-compulsive disorder (OCD) in Ness’s The Rest of Us Just Live Here, and the portrayal of schizophrenia in the video game Hellblade: Senua’s Sacrifice (by Ninja Theory) to assess how the texts represent mental illnesses and their social implications. The analysis shows that the three texts succeeded at creating a positive portrayal of the mental illnesses by removing generalized stereotypes about the conditions and by actively engaging readers, which fosters empathy.

Keywords: literature, mental diseases, disabilities, video games

Resumen

Este artículo compara y contrasta dos novelas y un juego de vídeo donde la participación de adolescentes que luchan contra diversas enfermedades mentales es fundamental para el desarrollo del hilo narrativo. El propósito es analizar la representación de la depresión clínica en It’s Kind of a Funny Story de Ned Vizzini, del trastorno obsesivo-compulsivo (TOC) en The Rest of Us Just Live Here de Patrick Ness, y de la esquizofrenia en el videojuego Hellblade; Senua’s Sacrifice de Ninja Theory para evaluar cómo los textos representan los padecimientos mentales y sus implicaciones en el plano social. El análisis arroja que los tres textos consiguen crear una representación positiva de las enfermedades mentales al descartar estereotipos generalizados sobre las diversas condiciones y al involucrar a los lectores en forma activa, fomentando así la empatía.

Palabras clave: literatura, enfermedad mental, deficiencia mental, videojuego

Introduction

Due to the contribution of disability studies, contemporary society is more accepting of people who have physical disabilities. However, one area still remains covered with prejudice and social rejection: mental disabilities. In fact, despite the global rise of diagnosed cases of mental illnesses, the discipline of disability studies has produced very little research concerning the aforementioned phenomenon. Fraser (2018) observed this peculiar situation in his book Cognitive Disability Aesthetics: Visual Culture, Disability Representations, and the (In)visibility of Cognitive Difference:

Cognitive disabilities, when juxtaposed with the increased theoretical, social, and cultural visibility of physical disabilities, have tended to remain disproportionately unseen. That is, those disabilities that might be classified as intellectual disabilities, developmental
disabilities, and psychiatric disabilities have not enjoyed as much critical attention by humanities scholars. They have not been as visible in society, historically speaking, or as frequently represented in cultural and artistic products, as have those disabilities judged to be physical in nature. In theoretical monographs, in the wider social environment, and in all manner of artistic texts it has historically been the case that one encounters deafness, blindness, and exceptional bodies much more frequently than one does persons who embody cognitive exceptionality.
(Fraser, 2018, p. 29)

In the specific case of Costa Rica, while Barquero (2019) reports that teenagers make up the population sector that shows the greatest incidence of suicide, Villalobos (2019) discussed the rise of mental health related consultations with Javier Contreras Rojas, a psychiatrist of the Health and Well-being Unit of the University of Costa Rica, and the expert argued that the prevention of mental breakdowns in the University of Costa Rica has not been a priority. He also observed that such units lack professionals to provide attention for the always
increasing number of cases:

“La UCR hace un gran esfuerzo para abordar la salud mental del estudiante, sin embargo, los recursos actuales son limitados. Al igual que en el resto del país, la salud mental está siendo más tratada desde un enfoque tradicional de atención. Sin embargo, se ha descuidado las otras áreas de promoción y prevención”, indicó Contreras Rojas.

Con respecto al servicio de psicología y psiquiatría que ofrece la universidad, el psiquiatra señaló que la demanda está aumentando alarmantemente. “Atiendo al menos cinco casos nuevos por semana y en ocho meses solamente he dado de alta dos casos. La situación en el servicio de psicología es similar, ya que desde hace un año no hay cupo para casos nuevos”, afirmó.
(Villalobos, 2019)

Of course, prevention starts with understanding of the subjacent triggers that lead to a mental breakdown. It is known that the causes of mental illnesses are multifold. Gutierrez and Contreras (2019) include factors that range from environmental to
neurological triggers:

Los efectos del entorno del individuo contribuyen significativamente a la aparición de los trastornos mentales. Algunos factores precipitantes son: sucesos estresantes, problemas familiares, otras enfermedades del sistema nervioso central y abuso o dependencia de alguna sustancia psicoactiva. También el estado de estrés en que vive la población mundial es un detonante importantísimo. (Gutierrez y
Contreras, 2019)

Efforts at prevention are lost, however, if society blinds itself with prejudice. In this light, awareness becomes paramount so that critical information reaches the target population in time. The obstacle that must be sorted out is how to engage the most affected sector of society in prevention efforts, namely teenagers and young adults, for they are generally resistant to information which they perceive comes from sources out of their own generation. The researchers believe that neither canonical literary works nor films are contributing to raise awareness about mental health in the youth. In the information age, it is the commonly frown-upon genres of young adult fiction and video games that are carrying out this function. Therefore, with the theoretical basis of disability studies, this article will analyze two young adult novels, Vizzini’s It’s Kind of a Funny Story and Ness’s The Rest of Us Just Live Here, and Hellblade: Senua’s Sacrifice, a video game by Ninja Theory, in an attempt to establish how these social manifestations, avidly consumed by teenagers, contribute to generate understanding and acceptance of individuals who suffer from clinical depression, obsessive-compulsive disorder (OCD), and
psychosis-triggering schizophrenia.

Justification

Although commonly disregarded by literary critics, young adult fiction and video games are two vehicles that can convey helpful information to teenagers effectively. Literary works belonging to the former category are treated as lesser literature with little academic value; the latter genre enjoys an even worse reputation in academic circles because literary experts, in general, are reluctant to perceive the interactive narrative of video games as legitimate. Both genres, nevertheless, have been increasingly addressing the problems to which more traditional literature has remained oblivious and have gradually stepped into the world of mental disabilities. Today, one can find multiple novels for young adults that deal with protagonists who are afflicted by an assortment of mental diseases that range from substance abuse to neurological disorders. Among these novels, the researchers chose Vizzini’s It’s Kind of a Funny Story and Ness’s The Rest of Us Just Live Here because of their candid depiction of depression and obsessive-compulsive disorder (OCD), respectively. In addition, it must be noted that contemporary Costa Rican literature does not provide many protagonists who suffer from mental illnesses. One is found in the short story “La orden que vino del cielo,” by N.P. Sommer (2019). In it, a young woman named Rigel suffers from chronic depression with suicidal tendencies:

Estaba sola, muy, muy lejos de mi familia y todo porque yo lo decidí. Así que enfermé. La ansiedad y la depresión me hicieron suya. Había sido una hija tan horrible,
que no había nada más que pudiera hacer. Nada de lo que hiciera jamás, sería suficiente. No había absolutamente ninguna manera de pagarle a mi familia todo lo que me habían dado y todo lo que yo les había hecho, aún si había sido con la mejor de las intenciones… Viendo entonces, que jamás serían tan felices como se merecían, traté de quitarme la vida en una de mis “auto reprensiones”. Tan cansada, tan enferma… Lástima que un compañero de la universidad me vio colgada del árbol más escondido que logré
encontrar. (pp. 26-27)

The short story, however, explains the narrator’s suffering and constant struggle as the result of her extraterrestrial heritage, which takes the focus away from the topic of mental illness to favor a more fantastic plot.

Mental disease, on the other hand, is nothing new to the industry of video games. From the fantasy-adventure genre to horror games, titles have included characters that are subject to mental illnesses since very early, such as Kefka Palazzo in Final Fantasy VI (1994). However, the great majority of such characters falls in one of two cliché categories: either the mentally afflicted character is a hero at peril (with a sanity bar displaying their deteriorating mental status) or, more predictably, the character in question is the villain, who has turned into a mass murderer because of their illness. In other words, video games have typically represented mental diseases in an extremely negative fashion, which conveys a message of social rejection for individuals with a mental disability.

Ninja Theory’s game Hellblade: Senua’s Sacrifice (2017) deviates from this pattern. Classified as an independent high-quality game (or an AAA title, which is what the industry calls games that rely on realistic-looking graphics, interactivity, and a large team of developers), the game attempted to re-create a more accurate representation of schizophrenia without trivializing the illness to favor game experience:

It is easy to see the pain and suffering caused by physical diseases or physical trauma; it is not so easy to see the mental suffering or trauma or severe mental illness. But what if we could find a way to see it? Games are capable of drawing you in for hours on end, playing the role of a character who's different from you, experiencing their perspective, and actively involving you in a world that functions with a different set of rules.
(Antoniades, 2017, 9: 03)

Therefore, the developing team worked closely with experts in health neuroscience and psychology, such as Professor Paul Fletcher (University of Cambridge) and Professor Charles Fernyhough, from the University of Durham. The team also consulted with patients who experienced psychosis and schizophrenia to create a more realistic game experience. The result is a game in which a young Celtic warrior called Senua battles through a world created by and interpreted through her own schizophrenia, drawing the players to understand the real source of her suffering. One must note that Hellblade is not an educational title because the game experience is not
conditioned by a didactic purpose: Hellblade strives at creating a close-to-life gameplay through in-game identification with people who suffer from psychosis, not to teach.

There is another justification for the present project: disability studies have not produced a substantial body of research concerning mental disabilities and the available research has a predominant medical outlook. This weakness was observed by Fraser (2018), who stated that, when dealing with mental illnesses, disability studies lack the social perspective provided by humanities:

While disability studies theorists, with much success, have worked to wrest discursive control of those disabilities taken to be physical – such as blindness, deafness, and missing limbs – from the clinical gaze, medicalized discourse has continued to be a predominant theoretical voice speaking on issues related to Down syndrome, autism, Alzheimer’s disease, and schizophrenia, for example. It is currently the case that intellectual disabilities, developmental disabilities, and what goes by the name of madness or mental disorder continue to be disproportionately explained by health field practitioners and not by humanists, even given the rise of humanities interest in the subfield of Mad Studies. (Fraser, 2018, p. 32)

With this article, the researchers also contribute with the expansion of disability studies onto the field of mental disabilities exclusively from the perspective of humanities, which looks for understanding and acceptance,
not from the traditional medical sciences approach that explains mental disabilities as a deviation from a notion of normality that has to be rectified. Major depressive disorder, obsessive-compulsive disorder, and schizophrenia, the three mental illnesses in this article, have profound socially-disabling consequences and, even under proper treatment, they always present a challenge for those who suffer them.

What is depression?

The term depression is loosely used today and, often, this vagueness leads to misconceptions. Sadness and depression are not equivalent terms; while the former is a natural emotion that all individuals experience in life and that improves with time, depression requires attention. The American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) specifies that depression is actually a group of disorders that have multiple origins and that impair the social functioning of the individual:

Depressive disorders include disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder... The common feature of all of these disorders is the presence of sad,
empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. (American Psychiatric
Association, 2013, p. 155)

Kanter et al. (2008) detail that what is commonly referred to as clinical depression is medically defined as major depressive disorder (MDD), and they provided a list of key symptoms that included suicidal ideas:

Depressed mood or dysphoria is the primary feature of major depressive disorder (MDD), the most common depressive diagnosis. In addition to this core experience, there are several other symptoms of MDD, including loss of interest in activities, sleep and appetite changes, guilt and hopelessness, fatigue, restlessness, concentration problems, and suicidal ideation. As discussed in detail below, the medical model holds that this constellation of symptoms represents a syndrome, but complexity is immediately introduced because the presence and nature of these symptoms vary considerably across clients (Líndal & Stefánsson, 1991). For example, some clients experience vegetative symptoms of depression (decreased appetite and insomnia) whereas, less commonly, others experience reversed vegetative symptoms of increased appetite and hypersomnia. Similarly, psychomotor retardation is more common and agitation is less common, and both may be demonstrated by the same individual at different times.
(Kanter et al., 2008, p. 3)

Environmental triggers can cause depressive disorders. Kanter et al. (2008) state that “private events labeled as depressed [sic] may be associated with overworking and receiving little reinforcement for long stretches of time or with grieving the death of a loved partner” (p. 3). Although it is easy to assume that excessive work and the loss of a significant other are conditions for adult depressive disorders, younger individuals are also exposed to those factors, which is causing a high incidence of clinical depression in teenagers and university students. According to Rodríguez (2019), depressive disorders top the list of mental illnesses in Costa Rica and they tend to affect mostly young people:

La depresión es el trastorno mental más común en los costarricenses. Solo el año pasado, 2.082 personas registraron episodios depresivos, según datos de Vigilancia de la Salud del Ministerio de Salud, revelados... por el Colegio de Profesionales en Psicología. Esto significa 41,6 personas por cada 100.000 habitantes... Las poblaciones jóvenes son las más afectadas. De los 20 a los 24 años de edad la incidencia aumenta a 85,2 por cada 100.000 personas, y de 15 a los 19 años, la incidencia es de 111 por cada 100.000.
(Rodríguez, 2019, pars. 1, 4)

Despite its high incidence, a judgmental attitude toward people who suffer from MDD still prevails, perhaps fostered by negative representations of depression in the media as Stressing (2010) observed in “Depression and the Media”: “Historically, the media has been blamed for presenting
inaccurate depictions of depression and other mental disorders and for stigmatizing them and making it difficult for people with depression symptoms to admit they need help” (par. 2). Vizzini’s It’s Kind of a Funny Story, however, is contributing to change that social stigma and, by immersing readers in the world of a teen with MDD, they can internalize mechanisms to cope with the disorder and empathize with those who
battle with it.

Representation of MDD in Vizzini’s
It’s Kind of a Funny Story

Craig is the protagonist of Vizzini’s young adult novel. The text starts by letting readers know that he has been ruminating and considering the idea of suicide because of academic pressure. He genuinely expresses his emotions to the reader, showing how MDD can affect people so that communication becomes almost impossible for them: “It’s hard to talk when you want to kill yourself. That’s above and beyond everything else, and it’s not a mental complaint—it’s a physical thing, like it’s physically hard to open your mouth and make the words come out” (Vizzini, 2010, p. 100). He is experiencing ambivalent feelings, which depicts clearly the confusion that MDD causes in individuals: “I want my heart but my brain is acting up. I want to live but I want to die” (Vizzini, 2010,
p. 1562). The novel neither romanticizes the desire of committing suicide nor presents Craig as a selfish individual: he knows how his action will affect his relatives and friends; however, the book validates his emotions without supporting the suicidal attempt or
judging the character.

Eventually, overtaken by MDD, which he imagines as tentacles that take hold of him, the young man decides to carry out his plan to jump off Brooklyn Bridge, but dials a suicide hotline in the last moment:

My heart radiates badoom, so I stand and shuffle into the living room and pick a book off my parents’ shelf. It’s called How to Survive the Loss of a Love; it has a pink and green cover….‘If you feel like harming yourself right now, turn to page 20”... ‘Every municipality has a suicide hotline, and they’re listed right in the government services section of the yellow pages,’ it says.
(Vizzini, 2010, pp. 1569,1570)

This quick turn of events helps to convey the idea that the person who suffers MDD is not alone and that there is help available, informing readers where to find it. Craig’s call establishes that a simple action can mean the difference between life and death. Craig looked for help (a psychiatrist and then the hospital), which exposes as a prejudice the common assumption that clinically depressed people, because of lack of will, simply choose not to live. In fact, the text acknowledges that, in the path to recovery, even small steps imply significant victories, such as the moment in which Craig, who formerly struggled trying to eat, tells his mother that he could finally finish his plate: “I shouldn’t be proud about this; it’s like really sad that this is my big accomplishment of the day...but I ate everything at lunch.”
(Vizzini, 2010, p. 2299). Upon hearing this, his mother stands up and hugs Craig, conveying to the struggling teen that his achievement is not minuscule by any standards.

The young protagonist, once admitted into an adult ward because of a repair in the space reserved to youngsters, had to interact with adult patients who had several mental illnesses like drug addiction and psychosis (Vizzini, 2010, pp. 2475, 2476). Craig, however, is not judgmental and the other patients also respect him despite the age difference. This understanding that they develop leads to openness and mutual support because they even realize that many famous people who contributed to the world actually battled a mental illness: “PEOPLE WITH MENTAL ILLNESS CONTRIBUTE TO OUR WORLD. It lists Abraham Lincoln, Ernest Hemingway, Winston Churchill, Isaac Newton, Sylvia Plath, and a bunch of other smart people who were kind of nuts” (Vizzini, 2010,
p. 2854). The novel, nevertheless, does not hide the fact that, sometimes, the friends of a person suffering from MDD actually push the patient into the abyss by showing lack of empathy instead of providing the support needed to carry on. This might seem a common cliche, but the novel introduces a different element: Craig’s best friend, Aaron, does not act out of ignorance, but he willingly ridicules Craig and calls his insensitive behavior an act of caring. Aaron learns that his depressed friend was admitted into a psychiatric hospital and calls him in the presence of a group of people, showing a complete disregard for the privacy of Craig in such delicate situation:

“I’m depressed, okay, Aaron?”

“Yeah, I know, about what?”

“No, man, I’m depressed in general. I have like, clinical depression”.... “Aaron, who’s in the room?”

“Nia, Ronny, Scruggs, uh...my friend Delilah.” I don’t even know Delilah.

“So all these people know where I am now”.... “I can’t believe you’re doing this.”

“Don’t be a girl. You know if I was in the mental ward, you’d call me up and rag on me a little. It’s because we’re friends, man!” (Vizzini, 2010, pp. 2584, 2585).

By presenting how some supposed friends actively behave in an insensitive way because, in their circle of peers, they obtain social prestige by putting vulnerable people down, this episode becomes cautionary for those teenage readers who are not personally struggling with MDD, but have some friend who is. It shows that lack of support is not always the result of ignorance, but of false friends who care more about themselves than others, a sad reality that many teenagers only discover after being hurt by the people they trust.

The most valuable message that the book transmits to MDD patients has to do with acceptance that the disorder can be kept under control, which lets the person lead a fruitful life, just as people in a wheelchair can learn that their disability does not define their individual worth. Teenagers who suffer from MDD know that their illness is socially disabling. This is a constant battle for them and should not be a source of self-bashing or embarrassment. Even though Craig and his friends from the ward did not get cured from their mental illness, they were able to develop different techniques to understand how to live with them:

I’m not better, you know. The weight hasn’t left my head. I feel how easily I could fall back into it, lie down and not eat, waste my time and curse wasting my time, look at my homework and freak out and go and chill at Aaron’s, look at Nia and be jealous again, take the subway home and hope that it has an accident, go and get my bike and head to the Brooklyn Bridge. All of that is still there. The only thing is, it’s not an option now. It’s just... a possibility, like it’s a possibility I could turn to dust in the next instant and be disseminated throughout the universe as an omniscient consciousness. (p. 4219)

The novel shows that Craig finally understands that having a mental illness should not imply a poor perception of oneself and that, even though he still feels all the negative emotions that he used to, it is possible to face the illness and live with it. The book shows that people who suffer from mental illnesses like MDD need support and the cognitive tools to understand their situation. In summary, Vizzini’s text removes the stigma of clinical depression and also helps others to envision what MDD patients endure.

The perception of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is another mental disability that has been frequently depicted in movies, mostly to achieve a comic effect, such as Jack Nicholson’s performance in As Good as It Gets (Brooks, J., Johnson, B. & Zea, K., 1997). The DSM-5 defines the condition extensively:

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Some other obsessive-compulsive and related disorders are also characterized by preoccupations and by repetitive behaviors or mental acts in response to the preoccupations. Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviors
(e.g., hair pulling, skin picking) and repeated attempts to decrease or stop the behaviors. (American Psychiatric Association, 2013, p. 235)

Picco L, Lau YW, Pang S, et al. (2017) found that OCD is generally perceived as a less disturbing mental disease than depression or schizophrenia. In their study, they offered
explanations for this:

It could be that people with OCD disassociate the disorder from negative public conceptions of ‘mental illness’ and perceive OCD as a less serious or dangerous condition, and consequently perceived stigma has no effects on psychosocial outcomes. Similarly it could be that those with OCD learn to distinguish between OCD thoughts and real thoughts, resulting in these people being able to reduce self-stigma by disassociating the OCD from
oneself… Finally while OCD refers to unwanted recurrent and persistent thoughts, urges, or impulses and/or repetitive behaviours that an individual feels driven to perform, these thoughts or behaviours can relate to a broad range of areas. It is therefore possible that this subgroup with OCD forms quite a heterogeneous group in terms of their specific OCD symptoms, which may result in variance in the extent to which they experience self or perceived stigma. (2017, p. 9)

It might be true that the general public and even individuals who have it perceive this disorder more mildly. This can respond to the lack on the available information about OCD in Costa Rica, as Bolaños-Palmieri, Chavarria-Soley, Contreras and Raventós state in “Un cuarto de siglo de investigación genética en los trastornos neuropsiquiátricos en Costa Rica”:

Dado que la población hispana está subrepresentada en los estudios epidemiológicos del trastorno obsesivo compulsivo y debido a su fenotipo heterogéneo, Chavira y colaboradores (2008) compararon la expresión de síntomas tempranos del trastorno obsesivo compulsivo en una población latina del Valle Central de Costa Rica con una población de California.

El objetivo del estudio fue identificar aspectos de la enfermedad que pueden variar de acuerdo factores culturales, así como la percepción de la enfermedad. Los resultados sugieren que los principales componentes
fenotípicos del trastorno son comparables en ambas muestras, y por lo tanto podrían tener una base biológica. Sin embargo, existe una diferencia en el nivel de discapacidad que causa la enfermedad, donde la muestra costarricense mostró una severidad menor de los síntomas y una menor tasa de trastornos del ánimo que ocurren junto con la enfermedad. (2019, p. 10)

Dr. Natalia de la Cruz (2018) states in her article “Trastorno Obsesivo Compulsivo” that OCD has a higher incidence during early years than it does in adulthood: “El trastorno obsesivo-compulsivo se presenta de 2 a 4% en niños y adolescentes, y entre 2 y 3% en adultos. La edad media de inicio se aproxima a los 20 años, sin embargo se estima que un 50% de estos adultos inician con síntomas a los 11 años” (De la Cruz, 2018, p.15). It is only logical, then, to expect that literary works that cater to the needs of teenagers, such as young adult fiction novels, start manifesting this reality that canonical literary texts have not dealt with, in particular when consultations are in the rise. In fact, De La Cruz (2018) concludes that health professionals must be prepared to face a potential OCD case: “la alta incidencia en el padecimiento de este trastorno obsesivo compulsivo nos enfrenta a una posibilidad muy alta de consultas de estos pacientes, por lo que debemos estar preparados para su atención” (De la Cruz, 2018, p. 17).

OCD in Ness’s The Rest of Us Just Live Here

Patrick Ness’s novel The Rest of Us Just Live Here stands as a bold text not only because of its focus on a
protagonist who suffers from OCD, but also because the novel proposes a narrative duality that reflects on one central conflict of adolescents: self-perception. In the universe of the novel, there are two kinds of teenagers: the extraordinary and the common ones. The special teenagers are called “indie kids,” and they are the protagonists of the interesting stories of juvenile fiction, such as the Twilight or Harry Potter sagas. Each chapter starts with a brief summary of the adventures of those indie kids as they battle unimaginable dangers and save the world. However, as the title of the book states, the focus of the narrative is placed on the teenagers that do not have any extraordinary ability, the common kids who were not chosen to perform wonders and that just live there.

In this sense, the novel deals with the seemingly trivial conflicts of normal adolescents, but this clever reversal becomes the core of a positive representation of mental illnesses because the ordinary kids are the ones who battle against them and their socially-disabling effects. Thus, while the protagonist, Mike, suffers from OCD, his sister, Mel, is a recovering anorexic, and both of them and their friends struggle to solve everyday situations related to finishing school projects, falling in love, trusting friends, and understanding imperfect parents.

Mike describes his compulsion, or the action that results from the obsession, as getting trapped in a loop.
Every time he has to wash his hands or face, he repeats the process of lathering with soap and rinsing it off until his skin becomes so irritated that his hands bleed or his face is so dry that it hurts. Although he is aware that this ritual is irrational and that it worsens the anxiety that he feels instead of relieving it, he cannot stop himself, which frustrates and embarrasses him:

I know how crazy this is. I know the feeling that I haven’t washed my face “right” makes no sense. But like I said, knowing doesn’t make it better. It makes it so much worse. How can I explain it? If you don’t know, maybe I can’t, but as I wash my face yet again, I hate myself so much I want to stick a knife in my heart. When Jared finally opens the bathroom door to see what’s going on, I’m actually crying. With fury. With embarrassment. With hate for myself and this stupid thing I can’t stop doing. I’m doing it again even now, knowing all of those things. (Ness, 2015, pp. 118,119)

The novel, nevertheless, does not depict him merely as a unidimensional dysfunctional person to provoke pity on readers. Instead, it shows that, despite the shackles of this mental disability, Mike is a brave friend that supports those he loves during the direst circumstances and who is capable of understanding the pains that other people have to endure:

Not everyone has to be the Chosen One. Not everyone has to be the guy who saves the world. Most people just have to live their lives the best they can, doing the things that are great for them, having great friends, trying to make their lives better, loving people properly. All the while knowing that the world makes no sense but trying to find a way to be happy anyway. (Ness, 2015, p. 237)

An accurate representation of OCD must include the repercussions of the disorder in the family of the patient, a situation often brushed aside by trivializing portrayals of OCD. Ness’s work, however, also pays attention to this dimension and does not present a world in which family members get along perfectly among themselves. This honest depiction of the shortcomings of family life is fundamental for teenage readers not to find the book patronizing; furthermore, the admission of families being less than perfect creates a sense of realism. For example, the novel acknowledges that teenagers and their parents often have a hard time understanding each other because adults see adolescents as self-centered while teens feel that their parents nullify them:

“Mike,” she says, warning. “The mistake of every young person is to think they’re the only ones who see darkness and hardship in the world”... The mistake of every adult, though, is to think darkness and hardship aren’t important to young people because we’ll grow out of it. Who cares if we will? Life is happening to us now, just like it’s happening to you. (Ness, 2015, p. 126)

If it is true that this representation of families might backfire since the validation of the conflicting feelings of teenagers could exacerbate frictions with their progenitors, The Rest of Us Just Live Here tactfully introduces glimpses of how adults see the world so that young readers understand that different perspectives do not necessarily imply visceral antagonism. The admission of Mike’s mother illustrates this: “Teens argue with their parents. That’s the law of nature. Doesn’t mean we stop caring about you. Doesn’t mean we stop being parents” (Ness, 2015,
p. 157). Such supportive reassuring of affection is fundamental for teenagers who are struggling with OCD to eventually understand that they are not alone.

In addition to the idea of parental support, the novel also conveys the powerful message that mental health professionals actually care for the patient and do not judge. One must understand that individuals battling OCD often feel self-conscious and that their own negative perception of themselves makes it difficult for them to look for professional help. Mike’s conversation with his therapist contributes to motivate OCD patients reading the book not to punish themselves with blame and accept medical treatment:

“Do you think a child born with spina bifida or cerebral palsy or muscular dystrophy is at fault for their condition?” “No, but–” “Then why in heaven’s name are you responsible for your anxiety?” “... Because... What?” “Why are you responsible for your anxiety?” “Because it’s a feeling. Not a tumor”... "Anxiety is a feeling grown too large. A feeling grown aggressive and dangerous. You’re responsible for its consequences, you’re responsible for treating it. But Michael, you’re not responsible for causing it. You’re not morally at fault for it. No more than you would be for a tumor.” (Ness, 2015, p. 216)

The Rest of Us Just Live Here creates the most empowering metaphor in its conclusion, nevertheless.
Mike always perceived his obsessions and compulsions as a loop that was, in essence, degrading; his OCD was a cycle of destruction. The novel reformulates this perception when Mike, after receiving treatment, and beholding his high school blown up by the battles of the indie kids, is able to transcend his anxiety to discover that life is also a loop: "‘Everything’s always ending. But everything’s always beginning, too’” (Ness, 2015, p. 3636). In this sense, the negative perception of the cycles of OCD is substituted by the notion that loops are normal in life and, therefore, nothing to be ashamed of. The novel, therefore, shows that life is a cycle, a loop where beginning and ending become unrecognizable. If life is a loop from which everything that is desirable springs, then his own compulsions might not necessarily be unproductive and Mike does not need to self-punish for them.

Understanding schizophrenia

In “Schizophrenia: Overview and treatment options,” Patel, Cherian, Gohil, and Atkinson (2014) offer a professional definition of this psychotic disorder that establishes its scope
and seriousness:

Schizophrenia is a complex, chronic mental health disorder characterized by an array of symptoms, including delusions, hallucinations, disorganized speech or behavior, and impaired cognitive ability. The early onset of the disease, along with its chronic course, make it a disabling disorder for many patients and their families. Disability often results from both negative symptoms (characterized by loss or deficits) and cognitive symptoms, such as impairments in attention, working memory, or executive function. In addition, relapse may occur because of positive symptoms, such as suspiciousness, delusions, and hallucinations. (Patel et al.,
2014, p. 638)

The DSM-5 classifies schizophrenia as a spectrum along with other psychotic disorders: “They [schizophrenia spectrum and other psychotic disorders] are defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms” (American Psychiatric Association, 2013, p. 87). In other words, schizophrenia (a kind of psychosis itself) complicates the individual’s social functioning.

According to Contreras, Montero, Dassori, Escamilla, and Raventós (2008), in Costa Rica, the onset of this mental condition can generally be found in early adulthood:

La edad de inicio de la EZ tiene significancia fisiopatológica y pronóstica. En nuestra muestra, la edad promedio de los entrevistados es de 38.95 años, con una diferencia significativa entre ambos sexos por lo que las comparaciones realizadas entre ambos grupos fueron corregidas por edad de entrevista. Nuestros pacientes presentaron una edad de inicio promedio (21.39 años) que está dentro del rango observado en otras poblaciones, tampoco hubo diferencia entre ambos sexos
contrario a lo descrito en la literatura. (Contreras et al., 2008, p. 157)

The government’s official data on schizophrenia indicate that the disorder is not as common in Costa Rica as MDD or OCD: “En cuanto a esquizofrenia en el año 2013, se registraron 215 casos y la provincia más afectada es San José con 113 casos” (Ministerio de la Salud, 2014, par. 8). The lack of exposure to the condition and the negative stereotypes propagated by the media might explain the general misinformation about the condition. As Patel et al. (2014) noted, there exist several popular misconceptions surrounding the term schizophrenia, such as that it has to do with dissociative personality disorder: “Contrary to portrayals of the illness in the media, schizophrenia does not involve a ‘split personality.’ Rather, it is a chronic psychotic disorder that disrupts the patient’s thoughts and affect”
(Patel et al, 2014, p. 639).

The American Psychiatric Association (2020) defines schizophrenia as “a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation. However, with treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished.” (para.1). Still, schizophrenia is the mental disorder that has been misrepresented the most by contemporary media, causing society to absorb stereotypical representations of the disease, such as it being an exclusively white-male problem. Owen (2012) ratifies this in her study “Portrayals of schizophrenia by entertainment media: A content analysis of contemporary movies”:

Over 70 movies were viewed, and 41 met inclusion criteria. A total of 42 characters met selection criteria for schizophrenia. [A table listing the movies and characters is available online as a data supplement to this article.] A majority of characters were male(American Psychiatric Association, 2013, p. 87)
(N=33, 79%) and Caucasian (N=40, 95%). Only two characters, both African-American males, represented minority(American Psychiatric Association, 2013, p. 87) groups. Estimated age ranged from preteen to 70 years old, and slightly less than half (N=18, 43%) of the characters were in their twenties. Almost half (N=19, 45%) of the characters were judged to be of below average or low socioeconomic status, and ten (24%) were judged to be of high socioeconomic status.
(Owen, 2012, p. 657)

The researcher, however, concludes that the media can become a powerful tool for the correction of the misinformation and the social stigma
around schizophrenia:

There is a need to provide accurate information about mental illness to counter the negative messages found in mass media. A few studies have found visual media to be effective in correcting misinformation about schizophrenia (40,45) and effective in increasing empathy toward persons with schizophrenia (43). Future efforts extending this line of research would contribute to the discourse on the optimal uses of entertainment media to correct misinformation about schizophrenia and to promote an informed understanding of those with schizophrenia and other mental illnesses. (Owen, 2012, p. 659)

Ninja Theory, the British video game development studio, embraced the challenge of creating a work that depicted the psychotic effects of schizophrenia in a way that could accurately convey the suffering of a person living with the condition and, in so doing, generate empathy in the player. The fruit of their efforts is Hellblade:
Senua’s Sacrifice.

Depiction of schizophrenia in Hellblade: Senua’s Sacrifice

Several objections arise when one claims that a video game such as Hellblade validates the experience of schizophrenic patients. After all, it is possible to dismiss Ninja Theory’s title as a product that wants to capitalize on the condition to achieve economic success. This argument, however, is questionable because the studio released the game as an independent venture. That is, had they looked for profit, it would have made a lot more sense to associate the title with a recognizable company in the industry. A more problematic concern is that of player/protagonist distancing: the hero of the game is Senua, a young female Celtic warrior who is facing Viking invaders somewhere in the 8th Century. The historical distancing between the player and the protagonist is obvious, but the psychology of the main character
establishes the greatest challenge. In her society, Senua is a gelt, a person “who was driven mad by a curse, battle trauma, or grief” (Antoniades, 2017, 5:25). In other words, not only must the game capture the player’s attention despite a colossal time gap, but it also has to draw the player to understand the psychotic nature of Senua’s real battles. Klimmt, Hefner, and Vorderer (2009) explained how a video game can achieve this through the process
of identification:

Our account of video game identification seems to be exchangeable with the notion of roleplay as active identity simulation, primarily because game interactivity leaves degrees of freedom to the player in terms of how she is acting out the character or role assigned to her. Because the game provides immediate feedback to player action (Klimmt et al., 2007), playing video games is also about self-adjustment to social forces: If players do not adopt behaviors compatible with what the game world expects from them, they will receive negative feedback such as failure or boredom. Clearly, identification and the concept of roleplay converge as theoretical construals of the video game experience.
(Klimmt et al., 2009, p. 361)

Therefore, the ludo-narrative in the game becomes an enjoyable alteration of self-perception in the player. By this mechanism it is that the game generates empathy toward schizophrenic individuals: players must become Senua to advance in the interactive narrative. In this way, the psychosis of the
protagonist becomes experiential for the player.

The fact that the game re-creates the symptoms does not imply that the portrayal of schizophrenia is positive. Therefore, Ninja Theory consulted with specialists in mental health and individuals who actually suffered from psychosis (Takahashi, 2019, pars. 5, 6) to create a validating depiction of the disorder. Of course, Hellblade is not the first game to introduce a character with a mental illness. The difference is found in the treatment of the condition: the work was produced to emulate the hallucinations from a medical standpoint, not merely from a stereotypical one and, to achieve this effect, the player is asked to participate actively. For instance, the game starts with a recommendation on experiencing it with headphones, for the spatial sound throughout the journey mimics what people suffering from psychosis often go through, that is, voice hearing (American Psychiatric Association, 2013, p. 87). The environment was created this way with the purpose of conveying the confusion of auditory hallucinations; voices assail the player from all angles since the beginning and contribute to convey the magnitude of the disorientation that schizophrenics suffer in the middle of a psychotic episode as Berrios (1982) asserted.

The reality distortions common to schizophrenics are also designed for active involvement, not merely environmental descriptions. The plot of the game draws from Norse lore and mythology, so the world comes to life with rich and often surreal imagery. Some elements make perfect sense for Senua within the context, such as the darkness consuming her from within,
and the player must come to an accord with the protagonist’s perception of reality, as distorted as it may seem, to understand the story and advance through her journey. This requires the player to perceive unrelated details in the environment as logically connected, a behavior called apophenia. Hoopes (2011) defines it as follows:

Apophenia is an error of perception: The tendency to interpret random patterns as meaningful… Apophenia results from the evolution of human cognition: The ability to spot and recognize patterns — patterns that represent things to eat, things to avoid, or things with which to try and reproduce — is an adaptation with positive feedback for survival. Birds do it, bees do it, even uneducated fleas do it. Plants do it. Even one-celled microorganisms do it. (para. 1, 3)

This behavior is common in schizophrenics (Stanely, 2014, par. 5). Thus, players must engage in pattern creation puzzles to be able to move forward in the game and this experience makes them understand another symptom of the mental disease that is generally trivialized by the media.

All the previous pieces together craft an experience nearly unrivaled in terms of getting as close as possible to what it would entail to live with schizophrenia and experience psychosis. This approximation to the reality of the disorder occurs since players must identify with Senua and work their way through the many trials challenging her. The interactivity of the game enables the player to become a person with psychosis and, thus, people can better
understand what individuals dealing with schizophrenia go through on a daily basis, which fosters empathy.

Even so, there are some who argue that the game failed its purpose. For example, based on her own experience of the illness, Lacina (2017) claims that the game fails short at representing schizophrenia accurately. Without wanting to invalidate her position, one must remember that schizophrenia is a spectrum and, hence, it does not manifest uniformly in all patients as Patel et al. (2014) stated: “The inherent heterogeneity of schizophrenia has resulted in a lack of consensus regarding the disorder’s diagnostic criteria, etiology, and pathophysiology” (Patel et al., 2014, p. 638).

Another complaint about the game does not involve the portrayal of schizophrenia, but the playability factor, a common concern for gamers. For instance, Saselandia (2017) voices his disappointment on the fact that the game lacks action to favor cinematics and free movement in the world: “Eso no tiene que ver con que Hellblade sea malo. No estoy diciendo eso, ni muchísimo menos... Hellblade es una película interactiva. Tiene muchísimo más de vídeo, de la palabra vídeojuego, que de juego. Y a eso está enfocado” (Saselandia, 2017, 1:59). While completely valid taking into consideration the requirements of the action game genre, this kind of dismissal rests upon the premise that the main purpose of any game must be to entertain. Bogost (2007) contradicts this position with his classifications of persuasive games:

I would like to advance persuasive games as an alternative whose promise lies in the possibility of using procedural rhetoric to support or challenge out understanding of the way things in our world do or should work. Such games can be produced for a variety of purposes, be it entertainment, education, activism, or a combination of these and others. (Bogost, 2007, p. 59)

The researchers agree that Hellblade belongs to the category of persuasive games proposed by Bogost and, therefore, judging the merit of the game using playability as the main criterion is actually a mistake. Also, the game’s nature places it closer to other forms of art, like the cinema or more traditional narrative genres
academically accepted.

Conclusions

After the analysis of the three texts, the researchers found that the young adult novels in the study transmit an empowering message to people who suffer from mental illnesses because the texts do not judge and present characters with positive traits. They also depict the struggle of the protagonists with their different conditions and validate emotions and additionally show how characters make critical decisions, such as to look for help when dealing with suicidal ideation or when they feel as failures because they require therapy.

The novels analyzed also generate empathy in those readers who do not live with mental disabilities because the plot of the text is not centered in the condition, which generates a sense of pity, but manifests the life of a teenager who has a given mental illness and leads a life like anybody else.
This conveys the message that mental illnesses are analogous to physical illnesses, which erodes the negative biases towards the disorders. In the world of the novels, the representation of MDD and OCD is positive because the texts convey the idea that normalcy is an unattainable social standard and, therefore, a mental condition is no different from other conditions that people may have. The video game chosen for the study also generates empathy toward schizophrenic people, but this effect is achieved by means of identification through interactivity albeit it sacrifices part of the gaming experience according to some gamers.

Concerning theory, more work needs to be done in Disability Studies to favor a perspective of mental disabilities that is not centered on the medical approach. In the same way in which humanities and social sciences contributed to remove the idea that physical disabilities had to be cured to achieve a sense of normalcy, scholars have to generate research that empowers individuals who battle mental illnesses so that they feel encouraged to live with their conditions. A desirable step toward this goal is to validate criticism in non-traditional works that strive at undermining negative depictions of mental illnesses, such as video games and young adult fiction.

Literary critics, thus, must revise the standards by which they evaluate the worth of contemporary literature in the information era. Neither do people consume literature in the same way they did before, nor literature has remained static. Video games illustrate once more the historical rejection of literary critics to accept that technology reshapes narrative. In the same way in which criticism first rejected photography, films, and comics to later accept them as legitimate sources of analysis, critics must understand that video games have evolved into a medium that offers a ludo narrative that enables participants to approach the story in a way that was not possible before. The researchers agree with Bogost in the categorization of certain video games as persuasive texts that can transmit powerful messages to players.

Also, if literary critics must be more accepting, gamers and ludologists must also learn to be less judgmental of video games that are willing to sacrifice the gaming experience to favor a narrative. It is still a long road before the goals of developers who care to rectify social misconceptions on mental diseases and the commercial interests of powerful gaming companies meet. In the meantime, gamers could be proactive instead of dismissing the games because of a misunderstanding
of their purpose.

Finally, in the current Costa Rican context, the researchers stress the importance of works like the books and the game considered in this study since the University of Costa Rica has declared a special interest in mental health for the year 2020: “Bajo el lema ‘Nuestra salud mental importa’, el 2020 será dedicado a la promoción y desmitificación de la salud mental por la Universidad de Costa Rica.” (Elizondo, 2019, par. 1). In this light, different social sectors (academic, health-related, political) should promote the socialization of such works and the production of more, along with more research on them.

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Recepción: 10-02-20 Aceptación: 25-09-20