If you’ve read the previous three parts of this series, hopefully you agree that video games and video game technology can help the PTSD healing process. Games themselves are lifelines for many people who are still struggling, or who are taking the hard but necessary steps to get our situations under control.

The stories I heard researching this series – stories of war, bravery, addiction, injury, loss, love and sacrifice; featuring the military, parental abuse, childhood cruelty, stalking and even religious cults… every one of these stories was worthy of its own video game. It was a huge honor and responsibility to try to incorporate their views into an article series with respect and dignity. It was humbling that strangers trusted me enough to share details of their diagnoses so I could verify their situations for this piece. I hope these people feel like they matter to someone, because their stories have so much inherent meaning.

There are still more people out there who aren’t getting help because they’re too afraid or ashamed to ask. They’re suffering alone and in silence, and I really hope that this series has made it clear that they don’t need to do that. Reintegration into society after traumatic events is still a major challenge, so I’d like to close this series with ten things the video game industry and community can do to be more inclusive of people with PTSD, as well as their friends and loved ones.

joel-and ellie in the last of us

1. Make yourself more aware of PTSD

This is a redundant request if you’ve read all four parts of this series, because you’re already on that path. However, if you’re a developer of any game hinging on a catastrophic event or personal tragedy, understanding PTSD will make your game more realistic – look at how various responses to trauma informed The Last of Us. No one expects a fictional character to be an embodiment of all people with PTSD everywhere, but if you’re a dev who wants to include a character with PTSD, or include events known to potentially cause PTSD, an understanding of the condition should be just another facet of the research you do for your game. There’s no point in getting the vehicles and weapons right and the radio chatter authentic if the emotional component lacks realism. A lot of people with PTSD bury their emotions deep, and that means there’s a lot of depth of character to draw from.

Does a diagnosis matter from a narrative perspective? Absolutely not. However, it’s important to separate what you see regarding PTSD in the media from the real life accounts, because the media tends to drain all hope out of the narrative.

2. Joke about triggers with caution

I get it: some people take the whole triggers thing to a ludicrous extreme, and the lectures, scolding and outrage get tiring. The temptation is there to cope with the politicized pageantry by cracking jokes. A certain amount of humor humanizes the situation, but not all jokes are created equal. Be very sure that what you’re mocking is an overzealous use of triggers, not the reality of triggers themselves. And be prepared to respectfully honor requests to stop joking about the subject if you get them.

The Last of Us

Sometimes I find trigger-related jokes funny, especially when they’re completely absurd: for instance, someone saying “Triggered by cute!” in response to a kitten picture. Other times I wonder if the person joking is actually mocking people with struggles. If someone stops the jokes when asked I assume they meant no harm. If they get offended by the request, that indicates a lack of empathy. Most people with PTSD don’t want people walking on eggshells around them, so go ahead and joke around. Just be prepared to stop if asked.

3. Don’t ever deliberately trigger someone

This may seem like an obvious point, but sadly, it’s not. Some people actually believe that forcing people to face phobias outside of therapy is helping them in the long run, but all you’re really doing is potentially ruining a person’s day. While it’s absolutely true that eventually trauma sufferers have to face our fears, that’s a process involving us and our doctors, not some idiot on the internet who thinks they know better than professionals with direct knowledge of a person’s case. Think a person is being “too sensitive” all you want, but respect their boundaries.

Furthermore, some symptoms of panic attacks mimic other health issues like heart attacks, so deliberately triggering someone potentially increases the burden on the health care system.

arkham-asylum

4. Don’t self-diagnose

This is another thing that should be obvious, but because of the state of U.S. health care, it’s not. If you think you have any sort of mental health condition, find out for sure. Even if you can’t afford ongoing treatment, a clear diagnosis makes self care a lot more effective. Not only is it important to find out for sure if you have a trauma disorder, you need to find out what kind of trauma disorder you have.

If you have another underlying condition, it can get in the way of the success of PTSD treatment. Mental health issues do not get better on their own. The sooner you seek treatment, the easier that treatment is going to be. If money is a big issue, there are types of professionals which are much cheaper to see than a psychiatrist. Social workers, for instance, are often a quarter of the cost!

5. Make resources readily available

A player’s favorite game franchise showing support the mental health process might be the tiny push they need to finally help themselves instead of suffering in lonely silence. With modern technology, games can easily set up menu links to crisis and support services, geolocated to a player’s area. Sure, a google search can do that too, but if the access tools come connected to a game, there’s a tacit permission to use them.

Wouldn’t it be cool if someone could access the National Suicide Prevention Lifeline, or similar crisis lines through the PSN, Xbox Live, or Steam? Even a slate during a load screen publicizing a support service is something. These things don’t have to be intrusive. I mean, if we have to see the Unreal or Havok logo displayed for the millionth time, why not a mental health resource screen too? Carry the Challenge suggests, for instance, that games with military themes carry a splash page linking to the organization: “Struggling with PTS? Don’t go it alone, visit www.carrythechallenge.org/regsitration”.

Games that focus on child abuse or abduction could similarly plug something like Canada’s Kid’s Help Phone. And of course, games that deal with suicide could provide the lifeline number: 1-800-273-TALK. Through these sorts of partnerships, video games could serve as important conduits to support, treatment, and community without affecting the play experience one bit.

batman arkham knight scarecrow

6. Support additions to ESRB ratings based on solid science

Even if you think that trigger warning culture is absurd, multiple studies have shown that there are certain behaviors that can negatively influence vulnerable people that are not currently included in ESRB ratings such as suicide, self-harm, and eating disorders. (For specific references, see part two of this series) Since these social contagion phenomena are backed up by science, there’s no reason not to include them in game warnings. Developers and community coordinators shouldn’t be responsible for product labelling when we already have an organization set up for this precise purpose. The ESRB doesn’t have to be restricted to shielding kids from things. It can be a resource for everyone. With a central body like this handling warnings, we don’t have to worry about this issue becoming radically politicized.

7. Be aware that trauma isn’t a fast track to evil

A lot of people think they know this, but they also believe that mentally ill people are more likely to be violent. Deny it all you want, but the statistics have been so consistent that there’s an undeniable disconnect here. A lot of games create sympathy for villains by showing a trauma they suffered, and that makes for interesting characters. But villains aren’t villains because they have mental illnesses. Villains are villains because they’re bad people.

Batman stories are wrong: trauma doesn’t turn people into psychopaths. I know, right? We can’t trust Two-Face’s origin story? Crushing! Past studies have shown that combat veterans with PTSD are not very likely to have Antisocial personality disorder. While trauma can be a motivator for a bad guy, it isn’t the motivator. Unfortunately, “crazy” is a temptingly simple shortcut to explain why an antagonist is stringing people up by their own testicles without taking up a lot of time defining the character.

If a developer wants to create an emotionally damaged antagonist, I say go for it. But make sure that their murdering rampages aren’t depicted as results of trauma, because unlike so many things people complain about in video games, in this case there’s actual evidence that it perpetuates stigma.

Tomb Raider Definitive

8. We’re not all heroes by default. All people – with PTSD or otherwise – are people

Although many heroes have PTSD, having PTSD doesn’t make you a hero by default. Giving a character a traumatic backstory because it’s an easy way to make them “likable” has gotten pretty rote. Having something horrible happen to supporting characters just to bump the main character’s story along – sometimes known as women in refrigerators syndrome – has also gotten old. It would be great if we saw resolutions to the stories of rape or abduction victims who aren’t the main character of a game more often than we do. It takes a really good person to make sure these innocents get the resources to recover from their ordeals.

Building up a personality – in real life or in fiction – exclusively based on traumatic experiences backfires in the long run because people striving for solid mental health don’t want to be stuck in the victim role forever.

9. We’re also not collateral damage. Stop hanging trauma survivors out to dry by panicking over bad mainstream press

The video game industry has a bad habit of bowing to external criticism regarding things like violence and sex. There’s a backlash against military games and any game that shows sexual assault, even when sexual assault is shown as a bad thing. This is terribly stigmatizing for people who have had these experiences first hand. “Where there is life, there is hope” doesn’t apply when some things are depicted as fates worse than death.

PTSD

For instance, imagine a woman developer wanted to tell the story of her emotional climb back from a violent rape. If she showed the rape exactly as it happened, this would be considered “problematic” media, because it depicts sexual assault: despite rape being a crime of violence, not a crime of sex, too many analysts still claim that sexual assault is included in games to titillate the audience. This false assumption potentially limits sexual assault survivors in telling their stories. I’m still deeply concerned that if people found out the true depths of what I’ve been through, they wouldn’t see me for my work anymore. That’s the last thing I want. I want the things I do, not the things that were done to me, to be what defines me.

There’s this false idea in the mainstream that gaming is a uniquely predatory, dangerous environment when it’s actually a surprisingly accessible creative industry. You wouldn’t know that, however, by the way some companies fall all over themselves to agree that so many games are terrible and that major change is needed. Forcing this “all violent and sexual media is bad” narrative has made it difficult for those of us who have survived violence or threats of violence to tell our stories without stigma and shame.

Do some games cross lines? Absolutely. Do some gamers act like bullies? Sure. But the way the press covers these issues is currently adding to a sense of hopelessness by treating traumatic situations as catastrophes instead of treating them like obstacles that can be overcome. We need to set a better example regarding attitude and tone.

tomb raider

10. Community Matters

A lack of social support is listed as a potential PTSD risk factor, and the process of beating PTSD can be extremely lonely. Therefore, community support can make a huge difference. Unfortunately, there’s a lot of distrust online these days. There’s been a lot of what I call “trauma theater” where people display screencapped threatening messages like billboards, followed by some pretty nasty attacks on that trauma theater, including accusations that people are lying or faking.

That’s a tough place to put someone who is still suffering the effects of trauma they experienced years ago. PTSD is hard enough to talk about without very loud fights of this sort going on; without having the pain a person went through and is still going through discounted. A small number of people do make stuff up. Most people don’t, even if you may consider their presentation to be tacky. But you wouldn’t know that from the reactions online.

Most people with PTSD want considerate treatment, not special treatment. Every individual’s experiences are different, so there’s no easy one-size-fits-all solution to including people with PTSD. All the product labels and warnings in the world don’t replace person-to-person communication. Bubble wrapping gaming doesn’t solve anything, but neither does denying that some accessibility considerations are reasonable.

Fighting back against PTSD ingrained in me that even the toughest, bravest people have limits. Every game developer, game journalist, YouTuber and game consumer has a daily choice to make regarding whether they’re going to be a force that hurts or a force that heals. Listening takes bravery. Compassion takes bravery. It’s much easier, much safer, to shut someone out. To tell them they’re making too big a deal about something. To insist their reactions “are just making things worse”. But at the end of the day, it’s not about politics or what you personally believe. It’s about getting people the help and support they need. That formula is different for every person, so no single person has all the answers. But people with PTSD have a unique wisdom born of trauma, so letting us speak and be heard isn’t just kind. It’s in your own best interests.

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