Design in Vienna:

SOTERIA: Playing Through Anxiety

An interview with Doris Rusch
May 17, 2017


Sabine Harrer

Anxiety, insecurity, avoidance: these may not be your first associations with video games. Alas, Austrian game design professor and author of Making Deep Games Doris Rusch, made a game about these issues. In Soteria: Dreams as Currency, we traverse the dim emotional world of Ana Carmena from the safe space of our windows computer. Ana is a digital version of our worry-crippled souls: She is driven by the fear to lose voice, the fear to be exposed and embarrassed, the fear to become anxiety’s puppet. In Soteria players are invited to travel a piece of the way with her, escorting Ana from a place of avoidance and defensiveness towards first attempts to confront and linger through fear.

Like in her previous games, Elude and Akrasia, Doris uses game rules and level design to make Ana’s inner processes tangible. Soteria’s architectures of play are rich with symbolism which Doris derives partly from introspection and from dialogue with others. I talked to Doris about how she went about making Soteria, and the point of making and playing video games about anxiety.

Sabine Harrer: How did you start out making a game about anxiety disorder? Why do you think it’s important to address anxiety through video games? 

Doris Rusch: I’ve witnessed anxiety close up in my family and know how it can impact people’s lives. Since “second hand” anxiety is quite common - anxious parents often have anxious kids - I also know what it feels like from personal experience. I’m seeing  way too much anxiety disorder in my students, too, who self-identify as suffering from anxiety and thus feel stifled in their studies and creativity. It’s a big issue and I really wished I could do something about it - to help in some way.

My previous games focused on modeling what aspects of the human experience “felt like” to promote dialogue and empathy, but with anxiety, this didn’t seem enough. 

Facing Fear

I started researching strategies to fight anxiety disorder and came across Prof. Reid Wilson’s approach of “wanting” and even “provoking fear”. Wilson is the founder of the anxiety treatment center in North Carolina and a Professor at the University there. I contacted him and he became our subject matter expert, providing literature and other resources as well as giving feedback to all stages of the design. The game aimed to communicate strategies to overcome anxiety disorder to players in an embodied - learning-by-doing-kind of way. So it was a combination of personal experience and subject matter expertise that shaped the design.


SH: Do you think there’s a moral duty for game developers to address such subjects more often?

DR: “Moral duty” is a big word. I wouldn’t want to impose any duties of this kind onto others. If someone wants to focus on entertainment games that’s cool. Escaping reality for a bit can have an important emotion regulation function - a way to deal with everyday hassles or just to have fun. We play the games we need, I think. If you need to sort blocks for a while to sort through your inner turmoil (unconsciously, of course), then do it. Someone needs to make these games, too! :) I, personally, feel the need to make games with a more explicit purpose, but that’s me. 

eyeball lamps, game art by Diana Kogan

SH: For your work on the game you collaborated with a mental health expert. Could you describe what that was like? How did you use anxiety research for game design?

DR: Reid Wilson's strategies to overcome anxiety disorder as described (and used successfully in his practice for decades are quite straightforward, so at least it wasn’t hard to understand. They also lent themselves pretty well to be used in a game. The only issue collaborating with any kind of subject matter expert is that they are very close to their area of expertise and it can be tough to negotiate “staying true to the content” with “creating something that engages players.” In Soteria this tension manifested mostly in the form of the main character - Ana - some players had big issues relating to. 

There is a lot of Ana’s voice over in the game and the first pass I wrote portrayed Ana as way more cynical. But that also made her appear tougher. We ran the dialogue past our SME and he said: “no, that’s not how someone with anxiety disorder would think, they’d be way more hesitant and reluctant to go towards the fear.” So I rewrote it all and the transition from very anxious to “confronting the fear” is way more pronounced. I love how the ending shaped up, but not everyone has the patience to play that far (even though the game is just 45min long). Some people who self-identified with anxiety disorder said, “Yes, that’s what it sounds like in my head, but I wouldn’t want to admit to it. No one wants to be that 'pathetic'.” Players not self-identifying with anxiety disorder sometimes had an easier time relating to Ana and just said, “Yeah, I believe it. I know so and so with anxiety and he / she sounds exactly like that.” I’m still not sure what to make of this and what would have been better. The idea is to play the game in the context of counseling or therapy where Ana’s thoughts could be reflected on. If there is resistance to relating to them, it could become subject of discussion: is it because it’s perceived as “too pathetic”, or “too close to home” or just plain annoying - why? etc.

music district game art by diana kogan

SH: You say that the essence of “overcoming anxiety lies in letting go of the desire to be safe and certain at all times" and to “invite anxiety along”, to “move towards the roar”. How do you guide players through this process?

DR: The key was to model resistance to fear first. To build fear up as something seemingly insurmountable so confronting it wouldn’t be trivial. We are all brave in the context of games (or at least braver than in real life), because we know nothing can “really” happen to us. So we couldn’t bank on players bringing their anxieties into the game space in a way that it made sense. Soteria is thus structured in 3 passes. The first one shows how strong the fear is. The shadow creatures always force Ana to retreat. This conditions players regardless of their emotional preconditions to fear the Shadow creatures in the context of the game. In the context of the game, they ARE insurmountable at this point and the only way to deal with them is to avoid them. This was disappointing to some players, who were used to being able to fight creatures in games and they wanted to do so in Soteria, too. But it would have rendered the message meaningless. It would have been useless to fast-forward to the solution. You first need to really understand and buy into the problem and then you need to earn the solution and it needs to be difficult - emotionally difficult. 

Soteria, computer game by Doris Rush

So we trick the player into using a common strategy of people with anxiety disorder: to increase safety measures and avoid danger (cause you think you can’t confront it). You can only sneak around danger and beam out of danger and then get this Phobos suit made that makes you invisible to the Shadow Creatures but also prevents you from doing what you need to do to win the game. You’re perfectly safe, but also perfectly stuck. That was important to show: the common sense strategy to deal with anxiety - what feels intuitive to do - to avoid discomfort and fear - is not helpful in the long run, if you want to live a full life. So the third pass of the game requires you to make yourself vulnerable. You need to take off your cocoon of fear - the Phobos suit - to liberate yourself. Only now do you learn how to confront the Shadow Creatures - how to endure the discomfort and linger through the fear and how to use dialogue options to actively provoke the fear. By now, players are conditioned to think there is nothing they can do against the Shadow Creatures (even we though we just showed them otherwise and taught them what to do) - the sneaking / stealthing behavior has become a habit. They panic when we take away all hiding places in the 3rd pass and they are suddenly face-to-face with a Shadow Creature. They have just been taught what to do, but very few actually do it at this point! The message that you can’t do anything about the fear has sunk in. Now, adopting the new strategy and fighting the fear means something. It has become emotionally hard to do. When they start to linger through the fear now (by smashing space bar), it’s an act of change, not just a gameplay convention to fight the bad guys.

Soteria, computer game by Doris Rush

SH: The game takes place in the inner world of player character Ana’s mind - a dark place inhabited by deceptive creatures. How did you come up with this kind of scenario?

DR: When I make a game about an inner conflict, I first imagine the world it is set in. It must be a metaphorical space, an inner landscape. I wanted something that felt confined, enclosed. Also nighttime seemed fitting - it’s darkest before the dawn. Fears as Shadow Creatures that roamed your mind-scape made sense, too. It’s not an entirely logical process - an image just emerges, usually, and I work with it. If it doesn’t hold up - isn’t deep enough, doesn’t have enough dimensions that fit the concept I want to get across, I keep digging until something presents itself. I’m proud of the three districts and locations: music district with music store, theatre district with puppet theatre and observatory district with observatory. They represent different aspect of general anxiety disorder: Loss of voice and self-expression in the music district represented by the bound instruments (it was hard to model these pile of bound instruments in a way where this concept actually comes across - shame); fear of being judged represented by the glare of the eyeball lamps in the theatre district and being fear’s puppet represented by the puppet in the puppet theatre; and fear of making decisions and being wrong represented by the locked path in the observatory and the start chart that shows the way (and that has to be disregarded if you want to go your own way). Coming up with these locations took some tinkering, because we didn’t want to be too specific and address only one certain form of anxiety disorder, yet we had to make it concrete in some way. Again, lots of introspection and letting the “guys in the basement” do the work ;)

computer game by Doris Rush - Soteria: architecture

SH: What are your least/most favorite reactions from players?

DR: Before I answer that, I have to say that our game has its issues. It is still a bit buggy due to the way we implemented it (hacking features in and adding them as we went along rather than starting with a vertical slice. This caused intricate and hard to find bugs that still catch us by surprise). It has some interface issues, too. Unfortunately, people don’t read. We spell everything out, it’s all there, but the way game information is communicated to the player could have been done better. That means, players often don’t understand what to do or how to play - e.g. that you can use the flashbang light only once (even though we tell you in the dialogue with Soteria’s priest and it appears in the item description on the screen). Anyways - these are usability issues that contribute to gameplay problems. And it drives me nuts to watch players struggle with them, although I know it’s not entirely their fault. Some of my least favorite reactions stem from these issues. Once people know how to play - and especially if they play through to the end - the “get it,” and most of those reactions have been positive. But sometimes players just focus on superficial things like, “this cat looks creepy. Why did you make it that way?” or “why did you choose this navigation system?” Reactions that say something along the lines of: “why didn’t you make the game I would have made???” to which I can only say, “then, please, feel free to make your own game."

One reaction that encapsulates why it was all worthwhile came from one 16 year old young man who, when he came to the last third in the game, when you go to kick the boss’ butt, he pumped his fist in the air and said “yes, captain!”, ready to take on the Fear. It was great to see that the part of the game that was designed to be empowering felt empowering to someone. We got a few of those reactions and that felt amazing.

computer game by Doris Rush - Soteria: Observatory art by Diana Kogan


SH: What did you learn personally from designing a game about anxiety? Do you have any tips for game designers who want to start making their own anxiety/mental health games? Something they should avoid or consider?

DR: I have become much more aware of how I relate to my own fears and I don’t let them slide so easily anymore. If I feel myself backing away because I get anxious, I wonder, what would Ana do? And how can I provoke the fear now? It helps. I have a huge fear of driving. But I’m driving! I don’t like it. I have to linger through the anxiety. I have to tell myself, you don’t get me to back away! I’m doing this. Come on - is this all you’ve got? I hear O’Malley’s voice (the cat that acts as your dubious mentor in the game). Making the game was therapeutic to me. I recommend people to make their own games about their own issues. It probably helps way more than playing finished projects. Unless you can play them in a context that promotes reflection and transfer to real life. It’s what I want to do: designing experiences as well as their contexts of use. I believe games can be powerful, but I’m skeptical about their often assumed omnipotence, Let’s just make a game about this problem and it will fix it. Nah, don’t think so. For designers, I’d say: be realistic with what you can accomplish. Enjoy the ride, because making games is awesome. And pick a topic that is really meaningful to you, because you’ll benefit from its creative engagement.


Doris C. Rusch is a game designer, researcher, play aficionado and holds a position as assistant professor at DePaul University. Before that she did post doctoral work at GAMBIT Game Lab, MIT, and Vienna University of Technology (Austria).