IAmA a medical doctor turned video game designer. AMA!

how pissed is your mom at your change in careers?

I'm married to a doctor, so we still have one doctor in the family. That calmed her down!

How pissed is your wife then?

I'd rather not say!

How do you ensure a diagnosis from actions in the game aren’t just the individual pushing boundaries because they are playing a game?

I would probably be locked up if psychiatrists diagnosed my mental health by assessing my actions within games.

This is the question we're trying to answer with our second project. Our first game aims at giving advice to the general public, like a self-help book (but with additional value as I've explained). The diagnosis question didn't come up.

Our second project is meant to diagnose and help cope with delusional thoughts. We are implementing different measures, including utilizing an observation known as semantic priming. Simply put humans recognize similar concepts before they even become aware of them. Passing obstacles on the game relies on the player reaching this recognition in the right time. Inconsistencies with these responses help us know if a player is cheating. However, from my experience people looking for help rarely cheat.

As someone who used to struggle with delusional thoughts and recovered, I’d love to help with some of this.

Thank you for the offer. Will keep that in mind.

Hi. I know this is late and you're not answering anymore but if you see this, I'm a hobby game designer, have messed around with rpg maker 2003 for over a decade before I decided to switch over to game maker studio 2. I'm not the best programmer but have been actively thinking about, making and researching game making for almost 20 years now.

I have also struggled with psychosis/schizophrenia for the last 5 years and still am, though things are finally looking a bit better.

I think what you're doing is great and if I can ever help by say playtesting your beta version or talk about game mechanics I'd be glad to do so.

Cheers and keep up the good work

Thanks for the offer. I'll keep that in mind.

Lots of games that I've played over the years have had a clear effect on my emotional state; League of Legends made me frustrated and angry, Team Fortress 2 was just good fun, and RuneScape and Pokemon make me feel at home. What kinds of games did you take inspiration from when designing your own? How did you think through what kinds of mechanics would be involved? What kind of emphasis was placed on the writing and worldbuilding?

This is a hard question. I am attempting something new here, so I'm learning all the time. Our first game was inspired by RPGs and visual novels. It's meant to teach coping strategies for common everyday difficulties. We chose to start with this game because it's relatively straightforward. However, it does contain puzzles that are based on neuroscience, and I believe that there's value in experiencing therapeutic advice in video game form compared for example to a self-help book.

Our upcoming project takes a completely different approach and is more like a bullet hell shooter. It's meant to help cope with delusional thoughts. So, the genre and the mechanics depend on the project and what conditions we're trying to address.

I like the idea of Doom being therapeutic. Is there much research on what style of games, whether they be tabletop or video, help address certain challenges people face? I'm on my last year of a social work degree and I'm curious if there's data on this for future therapy, or if you're blazing the trail so to speak.

I'm an old chef that decided to go back to college, but I have seen many people over the years successfully use gaming as a healthy escape from certain problems. I haven't looked into it yet though, so I'd love to know what papers exist, if any!

There are a few papers. Some authors even proposed interesting interactive diagnostic tools, that we're drawing inspiration from. However, the trail remains mostly unexplored.

Hi Dr Nassar

I'm a Speech Pathologist in Australia. I work as a part of a VR clinic providing rehabilitation for stroke and Neurology patients. We have anecdotally seen great response with physical, cognitive and mood in our patients. We are partnered with a university to conduct some research.

We use mostly existing games that are VR compatible. I have two questions for you:

I am looking at how I would go about creating a clinical informed game. What is your process from concept to finished product, and do you have any advice for transferring and incorporating evidenced based practice and best practice into a video game format?

Have you conducted any research on your software? Any tips for journals or resources? I'd love to build a body of evidence for this approach to therapy, but I'm not sure where to look.

All the best.

Edit: PS I am currently playing FFXIV!

Hi

This is a general question. I can talk about my specific field of expertise: psychiatry, which is a very unique field, since there are almost no objective diagnostic tools. I look for recent research about proposed diagnostic tests or observations. Psychosis is my main area of interest and you'd be surprised by the amount of cool and interesting diagnostic tools proposed. Video games offer the opportunity to make these tests more user-friendly and readily available.

I have to say that being a psychiatrist makes the process of starting something new relatively easy. Having no objective diagnostic tools or gold standards makes the people in charge more open to new ideas, as long as you're not conducting dangerous research.

Our upcoming game will be tested in a few psychiatric hospitals and clinics. And since it's a game, obtaining the necessary approvals (from ethic committees and the likes) is also simpler compared to other medical interventions.

Hey, thanks for sharing your unorthodox trajectory with us!

I'm curious what some of the most meaningful and resonant video games are to you, both (1) as a "regular" person, and (2) with a specific slant towards your values, beliefs, and what you do? If possible, I'd love to know the why as well, if you're willing or able to share it.

Thanks!

Thanks for the question. I've played so many video games over the years, and I have many favorites. However, the first that comes to mind is Final Fantasy IX, playing this game was when I realized the tremendous effects video games can have over my mental wellbeing. On a side note, RPGs in general is how I learned English (I'm not a native speaker).

More recent games include the Last of Us and God of War. I played God of War after my daughter was born. I was blown away by the connection I felt towards Kratos and the intense emotions I had playing the game. You can't get this intensity from a movie. I remember trying to explain this to some of my colleagues who were like "it's just a video game...".

IX is my wifes favorite game ever, and a fantastic title to make an example out of. Give 5 a shot too, the story is full of comedy and intense heartfelt moments.

A great game indeed. It's weird that back at the time it was considered one of the less good FF games.

Final Fantasy IX is also my all time favorite, and it’s always nice to see people enjoy it as well. Who is your favorite character?

Vivi, he's objectively the best character in my subjective opinion!

Were you inspired by bioware at all? They were also founded by Medical Doctors and churned out some really great games.

It made it easier for me to take this step knowing that someone had attempted this in the past and it didn't go catastrophically.

This was going to be my question as well. From what I know, Bioware went through a very similar trajectory too. They started making medical related software and moved onto storytelling experiences.

OP, with your background in psychiatry I'm excited to see what kind of cool experiences your team comes up with.

Thank you so much. We are a small team, so don't expect insane production values! But we are working on some innovative stuff.

You mentioned that the games could aid in diagnosis of illnesses such as schizophrenia and psychosis. I know that when I play video games I will often make choices that I certainly would not make in real life. How would you know a persons behaviors in game would translate to the real world?

Many brain processes happen before we become aware of their trigger. One example is the semantic priming I've talked about earlier; another is the different brain waves that we observe in certain conditions. Our upcoming game which is meant to diagnose delusions relies on some of these phenomena. For example, pressing the action button the moment the player recognized a semantic similarity but before they understand what they're seeing would grant them additional points. If this happens enough times the game start to recognize a specific thinking pattern.

What are your thoughts on Video Games as a coping mechanism?

As a kid, I used games as an escape away from my parent’s constant arguing and other troubling situations.

As an Adult, I game not to escape, but to relax and wind down, but I find myself so hyper-focused (escaping from reality for a bit), I miss cues from my daughter or wife at times (trying to break that mentality but it really is tough).

I’m excited to see the rest of this thread and the connection between gaming and mental health :)

Games offer a great coping mechanism, even if not specifically designed to help with mental health issues. Several therapeutic techniques, especially for anxiety disorders, teach things like shifting attention or executive brain skills, which is what many video games do without even realizing it.

I love this idea. Do you give these games away, do patients pay for them, or do you try to go through insurance? I can’t imagine trying to get my insurance to cover this considering I fight with them about just covering my annual bloodwork.

We went the commercial way with our first game because it was hard to convince health care providers of its value. I've given away more free download keys than I sold actual copies though. Our upcoming second game seems to be attracting more attention from insurance companies partly because it's addressing a specific condition.

What existing video games about mental health, if any, did you draw on when developing your own?

Celeste was a huge inspiration. Our game is totally different on the surface, but some of the ideas, especially towards the end are similar.

What are your thoughts on the therapeutic potential for virtual reality.

Some game makers are specifically targeting intentional mood alteration like creators of Liminal and Tripp and are suggesting potential benefits in medical indications. These experiences can be either passive or interactive.

I’ve noticed some creators are making very sophisticated perspective altering experiences with VR animation that play out as detailed immersive environments such as studio Syro’s Tales from Soda Island series.

What do you see as the role of passive versus active experiences in therms of therapeutic utility?

Virtual reality is being effectively used in exposure therapy, for anxiety disorder and phobias, which is very logical if you think about it. There's interesting research regarding other uses, nothing conclusive so far though.

I think that active experiences are where video games could offer a real breakthrough for mental health. One way to describe the mind is to say that it's the "dancing brain", or the dance of the brain. We've been trying to figure out mental issues by observing the brain in mostly static states, video games could offer ways to observe the brain's dance.

Hi Dr. Nassar,

I’m a family resident soon to be attending. I had a patients mother request a prescription for a game “endeavorRx” for her child to help treat his adhd. Have you heard of this game? Apparently you need an account and a verified adhd diagnosis to obtain it and play.

This opened my eyes to a potentially unexplored area of medicine. I feel that games providing therapy is definitely an avenue still to be explored for treatment options.

Any plans on doing studies on your games to see if they could potentially be used as treatment modalities? If so, and if they were found to be valid treatments, do you think insurance would cover it as a treatment?

Cheers and congrats! Matt

Thanks!

I've heard about endeavorRX but haven't tried it. There was an article about it on IGN. I guess it's how all the kids got to know about it!

Our second game which is meant to diagnose psychosis is planned for a trial in several psychiatric hospitals and clinics. Hope's Journey, being a general advice type of game, is less suitable for a study.

Why do so many medical practitioners turn away from medicine after just a few years?

I hear "he/she used to be a doctor..." a lot.

Burnout is one reason. However, in my case I don't see myself as turning away from medicine, I'm trying to combine my medical knowledge with my passion for video games.

Clinical PhD student here. I find the interpersonal behaviors and nonverbals (i.e. eye contact, fidgeting, mirroring behavior) can be important tells of how the person feels during an intake or if there may be more to the story so to speak than they’re saying directly. How would a video game - that is, something without inherent interpersonal interactions - assess these sorts of behaviors if at all? I just think there’s much more we get through talking than one way items like self-report questionnaires. Thanks! (Also love this idea though, and I wonder if it could make mental health more accessible or less stigmatized)

I don't agree that video games lack interpersonal interactions. There are multiplayer games, and even single player games have AIs so advanced nowadays that you can't help but treat them like you would a human. However, it's not as good as the real thing, nothing is. But I think it's impossible to meet the demand for therapists and mental health workers, there aren't enough human beings on the planet for that! Especially if you consider complicated cases that require follow up by several therapists.

Hi, I’m currently completing studies specific to video game design, what kind of ressources could I put some brain in to possibly get a better picture of the games your trying to make? I feel like it’s worth pointing out that I’ve been brainstorming ways to make video games for deaf/blind and children, since I too think there is a LOT of potential in video games

Hi, you could check out Hope's Journey, our first video game:

https://www.youtube.com/watch?v=3RsEUlj8EDE&t=7s

Would you say that any of your skills from being a medical doctor transferred over into game design? If so, which ones, and how?

Many! Turns out being able to think algorithmically is a great skill to have as a game designer. Moreover, the games themselves aim to help with different emotional and mental health issues, so having the medical knowledge is a huge bonus.

Any YouTube videos on this?

An awesome person made a walkthrough as well. Careful though, it's full of spoilers:

https://www.youtube.com/watch?v=iHng78B5ygE&t=8s

Can you describe in more detail how you hope video games will help folks with psychosis?

Also, I've always wondered about video games helping folks who have had a stroke recover. Are there any games out there for CVA recovery? I work with a lot of patients who experience neurological deficits and would love to know about more resources for them.

Neurology is not my field of expertise. I addressed the psychosis question in previous comments. An important feature of psychosis is that it distorts the way we think, makes our thoughts less organized, this usually manifests in delusions (we reach illogical conclusions because our thinking process is distorted). Games relying on the player responding quickly to environmental cues could give us clues about their thought process.

Where did you go to school to be a game designer?

I didn't. I studied medicine, but I've been a gamer all my life, and learned game design mostly from online tutorials.

Cool! Where did you start when it came to learning game dev? Certain coding language, or tool?

Source: I’m learning to switch from PM in big tech to game dev

Like I mentioned in the post. I started simple, made some games using RPG maker for psychoeducation. I'm learning Godot right now.

Hi there Dr. Nassar, fellow physician/video game enthusiast here! First off just want to shout out how awesome it is to see someone melding their two passions, and using video games to try to benefit patients. Also big ups on loving God of War; that's probably my go to game in recent memory to convince people that games are an art form just as much as cinema or anything else.

As for a question, I was wondering if there were any games you've played that you have drawn inspiration from for your own game development, and also what your take on some games that have come out recently to some critical acclaim that explore mental health and inner journeys, such as Hellblade: Senua's Sacrifice or What Remains of Edith Finch?

Thank you!

I've played Hellblade and I liked it a lot. It's one of the few games that does mental health right. Its portrayal of psychosis could be used to teach medical students!

Celeste inspired me a lot. It's totally different from Hope's Journey aesthetically and gameplay wise. But under the surface there are many similarities, especially towards the ending of Hope's Journey.

Any thoughts on the ethics of what Dr. K is doing?

I think he's making a bigger issue of video games addiction than what it really is. Don't get me wrong, some people do play games compulsively to the degree that it starts affecting their quality of life. However, in my opinion it's not as prevalent as he'd like people to believe, and I don't agree that it needs a separate diagnostic category.

What are your thoughts on Surgeon Simulator?

Never played it. On a related note though, when I was a student I was asked to help a senior surgeon with laparoscopy, it was during my Wii phase. He was very impressed with the way I handled the laparoscope he didn't believe it was my first time using it. It felt very similar to using a Wii controller!

Do you think games can potentially increase peoples' empathy? Are there techniques for encouraging people to think about the lives and feelings of others? I'm an amateur/hobbyist game dev and I'm interested in experiences that might help people move past feelings of apathy etc.

This is a very complicated subject. I don't have a precise answer, but I think it would depend on the reason behind this lack of empathy. If it's due to environmental factors (lack of supportive environments, family issues) I think video games could certainly help, for example by providing corrective experiences that challenge the player's misconceptions. However, lack of empathy due to neurological or organic conditions is a more complicated issue.

Hey, I have been recently diagonsed with some level of depression, one of the questions the lady asked me was “Have you lost any interests?”, Yes I did, Gaming. How would you recommend to me to get into it again? If I start I just feel anxious and not focused because of other life commitments. Thanks

I think the relation between motivation and action is not unidirectional. Sometimes it takes action in order to build up motivation. You could start with a simple game, something you've played before, that doesn't require a lot of effort to get into.

Have you heard of healthy gamer? I think you would be a really cool interview guest.

I have, but I think our views are different.

Hi there! I love what you’re doing and feel like it could definitely be doing lots of good!

My question is, what RPG’s had the most profound effects on you growing up? For me, they had to be FF6, Earthbound and Lufia 2. Cheers.

Lufia 2 was one of my favorite games. I remember spending long hours in front of the TV with an English dictionary and a controller, which people found very amusing!

My favorite RPG remains FFIX. I hope the rumors about the remake turn out to be true.

Have you designed any games that deal with depression and if so what did they involve?

I’m also a huge gamer and in my third year of med school. Psych is one of my top choices for a residency currently. I also have the classic depression/ADHD duo, hence the question about depression.

Our current game teaches the basics of CBT, which is meant to help with depression and anxiety. Depression comorbid with ADHD is a more complicated condition (and sadly not as rare as we once thought, especially in people diagnosed with ADHD at an older age).

Do you play healer class when you play games?

More a wizard / black mage type.

Hi Dr Nassar! I chose to go on the adventure of learning to make games in my free time. As someone who's presumably similarly unskilled with art and music as me, how do you make your games look and sound nice?

Hope's Journey looks like it's made with RPG maker, so are you using pre-existing art then? What about the music?

If using pre-existing assets, do you have any plans to learn making your own art or music? I decided that I want to learn making my own and was wondering how other newbie game devs deal with this.

Bonus question if you have time: what research are the "neurological" puzzles based on? If you have keywords for pubmed or some names that would already be awesome :)

Many of the assets are premade, but after a few years of working with pixel art I reached a level where I'm comfortable enough with GraphicsGale to make my own adjustments and tweaks. Although graphics weren't my first priority, I ended up making most the maps for Hope's Journey. Beyond these adjustments and tweaks I don't see myself making my own assets or music, I'm focusing on designing the games' mechanics. Would probably continue buying assets / using premade ones unless a game ends up making serious profit, then I'll consider hiring an artist or musician.

I'm afraid I can't find the specific research paper right now. It's in my office though, will send it to you when I get a chance.

How long did it take you to get up to speed? I have ideas for games I’d like to make.

I'm still learning! But I have to say that I was always into video games and video game development, watching videos and learning stuff all the time, even before starting developing my own games.

Whats your thoughts about from soft games? Its a popular theory that those games games cured depression for many people because of how it helped the notion that difficulty can be overcome by consistant efforts.

Beating the original dark souls improved my self esteem tremendously. So maybe there's some credibility to that theory!

Very cool!

Any thoughts or opinions on bridging gaming/cognitive training approaches with negative sx/cognitive impairments? (Maybe even abi. One thing at a time).

Or hell. Social skills training. Practicing various tasks/improving adapative behaviors/independence in ASD. There were ideas for VR prior to the pandemic that were halted before big trials began.

Diagnostic use is certainly an interesting approach (e.g. tova as supporting evidence). If there was something that could replace the ados or adir for asd, you would be a beloved hero (adi r =takes forever. Ados... yeah).

Either way. Data collected even if for dx could have potential to inform approach to tx. Best of luck and thanks for your work.

Edit: had a moment for more than a glance at website. I see is tx not so much dx (not sure why i had thought the other way around). Its hard work! Its one thing to come up with a manualized therapy approach. Another to practically and meaningfully teach+practice in a game. Very very cool.

Thank you for your comment.

I am an optimist. Many in the field agree that interactive software could be used to diagnose mental health issues, however, only few think that it could be used for treatment, especially for negative symptoms / cognitive impairments, seeing as these are probably due to irreparable damage to the CNS. However, I've seen people's social skills and cognitive faculties improve after participating in intensive rehabilitation programs, and we know now that the brain is not as static as we once thoughts. These are reasons for optimism.

I've learned so much mythology through video games. I think they're a great platform for learning! While in uni I definitely thought about making games to help memorization for medical terms.

Dbt has helped my mental health tremendously. (Please put dbt in it!!) There's little therapy for agoraphobia though other than exposure therapy.

What mental health issues are you targeting specifically?

I agree that video games are a great teaching tool. I learned English playing RPGs as a kid!

Our first game, Hope's Journey, teaches the basics of CBT, including third wave approaches for dealing with anxiety and stress. It is meant for the general public.

Our second project, the one we're working on right now, is targeting psychosis and delusional thinking.

Have you tried psychonauts 1/2? What did you think of it?

Not yet. However, after releasing Hope's Journey I was shocked to discover that some of our concepts were very similar to Psychonauts. Planning to play them after finishing Horizon Forbidden West!

I'm curious about the impact this change has made on your financial situation. To go from a doctor to an indie game dev is such a massive downgrade in income. How did you survive?

Mostly savings. I don't have to pay nearly as much taxes as I did in the past! My wife still has her job. But you know, I'm not as worried about money as I thought I would be.

Have you tried reaching out to a major publisher? I reckon the kind of stuff you're doing would be well supported by Ubisoft

Tried a few. Didn't receive a single response. Might try Ubisoft, I have nothing to lose.

This is a supper interesting idea, as someone who suffers from autism I must ask, would there be a way for a theoretical videogame to help recently diagnosed people learn how to manage sensory inputs, better understand social interactions and other troubles that specifically affect people with autism?

Thank you!

I can see a video game doing that, especially with helping in understanding social situations.

MMORPG player and former progression raider here! I know when I was raiding, it helped me quite a bit in terms of learning group organization skills and leadership - skills that I used successfully in the workplace and at home. But prog raiding always comes with its own issues - frustration at mechanics failures, squabbling over loot, "Healers Adjust" egotism, "git gud"-style feedback without assistance in the actual gitting of the gud.

How would you attempt to replicate the euphoria and camaraderie of completing a difficult raid (puzzle?) together without the negative emotions involved?

How would you get players to realize that the raid's only solvable if they all work together and appreciate the efforts of others?

And finally, how will you do this with tolerance for disability built in? I had to stop raiding because of an autoimmune disease that affected my fingers, but I miss that joy of a hard obstacle being conquered with friends.

These are a lot of hard question!

I don't think that removing the negative emotions from an experience is very constructive. I'm not looking to make feel good games, other studios are doing a better job at that. As a therapist I think that experiencing the negative emotions and surviving them is how you build resilience.

I’m a neuro resident and I have seen some visual cue games for concussion recovery. Any thoughts?

We use similar approaches to treat cognitive deficits / negative symptoms in schizophrenia. I think the problem with these approaches (at least in schizophrenia) is that they try to treat a symptom instead of addressing the root cause which is the distorted thinking process.

How realistic is Surgeon Simulator?

Haven't played it.

What are your thoughts on the video game that received FDA approval for tx of ADHd?

I haven't tried it personally, however, it's worth noting that it's not meant as a stand-alone treatment.

Do you ever incorporate your medical skills into the video game world?

Yes. As stated, Organic Apps aims to make therapeutic video games meant to help diagnose and treat different mental health conditions.

Have you ever thought of combining it with wearable tech to have insights on the biometry of your patients while they play?

One of the major issues with psychiatric diseases is that to this day we still don't have any objective diagnostic measures. Wearables are neat, but they are yet to provide any tangible value.

Thanks for the AMA.

When I read your description, I thought of Hellblade:Senua's Sacrifice. Have you played it? If so, what's your opinion on it?

Second question: What's your favorite game except for your own game?

Of course I did! They did a great job portraying psychosis, even better than some acclaimed movies IMHO.

I have many favorite games, but I'd say FFIX ranks as number 1!

Back when you were practicing, did you ever have issues when Larry Nassar was on trial?

No relation. It's a very common name!

Hello doc, hope you're doing well, what do you think of play therapy?

I'm afraid I'm not familiar enough with the subject. I worked mostly with adult patients.

Hi Doctor! Curious to know your thoughts on Senua’s Sacrifice, assuming you’ve played it. It was a strange and powerful experience for me, which first opened my mind to the possibilities of video games in successfully expressing/conveying unfamiliar mental states. What did you think of it?

This question has been asked several times. I guess it only shows how great a game Senua's Sacrifice is!

As I said before I've played it and I liked it a lot. I think it's one of the best portrayals of psychosis in any medium, even better than some acclaimed movies. It really proves how powerful a tool video games are.

Maybe on a slightly glib note, what do you think of surgeon simulator, as a medical professional?

More seriously, is there a particular mood you look to achieve during a gameplay experience? How do you blend “fun” and “learning” (or any other objective of your work?)

I'm not looking to achieve a specific mood. Other developers have done and are doing this in better ways than I'd ever hope to achieve.

What I'm looking to offer is practical therapeutic content. Our first game teaches the basics of CBT in a manner combining visual novel, puzzle and adventure elements. I believe (and it has been shown by some recent papers) that learning these techniques interactively is more effective compared to other methods. Our games are fun and entertaining compared to classical therapeutic apps, but I'm not going to claim that they are as fun or as entertaining as Super Mario.

How would you feel about making a realistic video game remake of the board game Operation?

Would need zombies for it to be commercially successful.

In your expert opinion, how realistic is Dr. Mario?

I'm in position to judge such a worthy physician!

I think I pulled my duodenum. Can I push that back in place with a kitchen spoon while doing a legendary run in Halo 2?

Halo 2? Is that a new game?!

How did you start? What did you study to become a game designer?

As I've said in my post, I started making simple games for psychoeducation using RPG maker. Learned most things online.

What would make the next call of duty a actual good game like the old days?

A time machine!