I’ve been thinking about this topic a bit recently (for no particular reason recognized by my conscious mind, and nothing decipherable from my dreams, at least), and I thought I’d contribute my personal thoughts and opinions on the matter. A few prefatory notes:

1. If you’ve followed my blog for a while, you may remember that I’ve now lived with clinical depression for fully half of my life (thankfully well controlled so that its effects on me are minimum or none). I know what it’s like to struggle against mental illness, and I understand the stigma that still, unfortunately, exists in the minds of many. But this post isn’t about my experience. I believe that this is an important issue for all roleplayers, not simply on an awareness basis (though that, too), but also because mental illness, if handled well and by agreement of all involved, can add depth and drama to a story–but also runs a high likelihood of being offensive, misguided, and ridiculous when the topic is not handled with care.
2. You’ll probably also note that my writing on gaming has been focused on Fate RPG at present. The Fate Accessibility Toolkit has been recently released, and my understanding is that it has a treatment of this topic as well. I have not read it, so I don’t know how my opinions fit with the approach therein. Regardless, I can’t imagine that reading multiple opinions and approaches on the topic would be harmful–likely it would be helpful.
3. I am not a psychologist or psychiatrist; I’m a lawyer, gamer, writer and aspiring theologian. None of my comments here should be taken as an attempt at serious medical commentary: we’re not talking about the pathology of actual mental illness here; we’re talking about fictionalized mental illness portrayed for dramatic and narrative effect in games we play–and portraying said fictionalized diseases and disorders in a way respectful to and mindful of those who live with the reality every day.

Getting It Wrong
I don’t have any particular instances I can think of where I had a player roleplay a character with mental illness in a way that was anything other than cartoonish, and that’s perhaps part of my basis for writing this post.

Let’s take an example many of us will be familiar with–a character playing a Malkavian vampire (or Malkovian if NWoD) in Vampire: The Masquerade (or Requiem, if you prefer). I have only seen players portray such characters as a bundle of nonsensical nonsequiturs intended to justify chaotic randomness and the player making all decisions by whim or, even worse, a roll of the dice. This is painful to all involved, except perhaps the player of the character, which is bad RPG group dynamics.

Not to offer criticism without an alternative, here’s how I think a typical Malka/ovian character should appear at the table: entirely “normal” most of the time. Then, occasionally, the character says something off, but in a way that might be a miscommunication, a bad joke, or something else that’s weird but only disturbing or threatening according to a certain interpretation. It’s only occasionally that mental malady truly overtakes the character, triggered by elevated tension or specific events, when it becomes painfully obvious that the character is gripped by beliefs or motivations that simply do not match with reason or the facts of the world. That inability to let go of incorrect beliefs or to overcome unwanted and unreasonable compulsions is where the horror of mental illness is found–for sufferer and for those around him or her. Vampire is a horror game, however, so that’s the point of portraying mental illness or psychological conditions in such a game–whether as a vampire who inevitably suffers from such or as a different type of character who suffers from the same for reasons mirroring those in the real world–unfortunate genetics, after-effects of injury or physical illness, unhelpful thought patterns maintained over time, mental trauma, etc.

The Age of Diagnosis by Committee
With the availability of Google, Wikipedia, WebMD and the like, there’s a growing habit among we who lack any significant training in psychology, to attempt to diagnose personality disorders or pathological mental illness in others. Most often this is our political figures (there’s even a current research trend to analyze sociopathic traits in the types of people who run for or are successful in political office, even if otherwise seemingly mentally healthy) and our celebrities, but it just as easily infiltrates our gossip about the people with whom we work and live.

In some ways, this is nothing new. Since the birth of neuroscience and psychology/psychiatry as well-respected fields of academic and scientific inquiry, historians have jumped at the opportunity to diagnose major figures in our past (particularly those whose behavior was erratic or who had a reputation in their own time for being mentally ill) according to modern psychological theory. There’s George III of England, who likely suffered from porphyria, any historical figure who claimed to have visions from God, who are most often retroactively diagnosed with either temporal lobe epilepsy (TLE-X) or schizophrenia, and plenty of persons we’d like to think of as having a mental illness to explain their crimes against humanity.

Of course, except in limited circumstances where DNA testing might be available and a mental illness had a wholly or mostly genetic cause, we really can’t know what historical persons did or did not suffer from. This trend is less about those analyzed and more about us, about the human tendency to want to categorize things into neat boxes to avoid ambiguity and uncertainty.

There is also a tendency to use this tactic to elevate our historical milieu over the past. We can says things like, “There was so much violence in the middle ages, a sociopath wouldn’t just find it easier to survive, he’d find it easy to thrive!” i.e., thank God we’re so much less violent and so much more reasonable now than people used to be. I doubt that very much. In the case of the TLE-X explanation, the point is most typically to apply a materialist paradigm to the past so that we can laugh about how backward and superstitious people were then and how much better we are now for embracing “reason” over religion (despite the obvious logical, philosophical and epistemological flaws in such arguments, which I’ve addressed elsewhere on the blog).

It’s precisely in the uncertainty and ambiguity inherent to mental illness where we find narrative drama. For several reasons, I’m going to suggest that we put down our DSM VI’s and focus on narrative.

Why Diagnosis is Unhelpful For RPGs
(1) It causes us to use stereotypes.
It’s likely everyone reading this (or nearly everyone, at least) has read or played in an RPG with a sanity system. I’m not going to point out any offending games specifically, but these systems tend to play out in one of two ways: Most often, the system involves preset categories of mental illness (usually given the names of official categories that might be found in the DSM) and prescribed behaviors for each category as a mechanic for something that, by its very nature, defies easy mechanics and particular expectations. Alternatively, the system relies on discrete behaviors rather than full categories.

Here are some of the problems with these systems: First, if the result of the “insanity” (a problematic word for such systems anyway) doesn’t match the instigating events, the disconnect makes the system lack any verisimilitude, which most often causes players to lose any interest in believability and play the system and its effects for laughs. Second, these systems often focus on limited behaviors, which builds idiosyncrasy in a character, but not necessarily serious character development. When the behavior, rather than motive, is the issue, the risk of cartoonish roleplay becomes exponentially higher.

This kind of system further pushes us toward caricature rather than character because it operates as a shorthand to approximate mental illness without much care toward our actual proximity to the truth of experience. My players love to roleplay, but most of them are not interested in doing a lot of research to play their characters. I cast no aspersions on that; every roleplayer has different goals in approaching the game and I suspect that most gamers want to focus on the game without having to do “homework.” But it means sloppy roleplaying on issues that require great research or experience to do well, like mental illness.  This is poor form on its own, but when you have someone at the table who has experienced mental illness, personally or in close loved ones, and who potentially continues to struggle with those issues, such a lackluster approach shows a disrespect and lack of empathy destructive both to relationships and to a safe gaming environment.

(2) It makes us rules lawyers of character.
I’ve played with enough gamers who believe that the rules as written constitute the “physics” of the game and trump everything else–fun, good narrative, drama, efficient play, etc. My personal opinion is that the culture, if not the history, of D&D pushes people toward such a belief (I understand that Old School gamers will vehemently disagree; this is a debate for a different set of posts).

When we translate this approach to a set of rules describing a mental illness a character may have, then the rules of the mental illness become a permission for bad behavior by the player. This is not a result of roleplaying mental illness itself, rather it is a prioritization of discrete values and prescribed results (i.e. rules) over the reality of mental illness. “The player argues, ‘because I have…uh, kleptomania…I have to steal everything I can from the Baron. And because I have schizophrenia, I believe that the rest of the party members actually did it, so I blame them.'” Not fun for those other players, probably not relevant to the narrative, not a development of the player’s character in any meaningful way and not a cooperative approach to roleplaying in a group–in other words: annoying, unrealistic, and offensive.

Despite the categorizations of the DSM VI and its predecessors, every presentation of mental illness is different (it is, after all, an expression of a unique soul and psyche), so pigeonholing a disease into a set of rote behaviors is contrary to experience.

It is commonly said that naming a thing gives you power over it. This may be the exception that proves the rule, where naming the thing gives it power over you as you feel obligated to meet a culturally–not experientially–based expectation of the thing so named.

(3) Human behavior is based on a complex interaction of beliefs, the matrix of preferences and thought structures that constitute personality, and experience. Not on hard and fast rules.
Again, I’m not an expert in psychology or psychiatry. But my training as a foster parent has opened my eyes to the complexity of behavioral motivations in children, particularly those with traumatic backgrounds, and I can’t imagine that the same is not true of adults.

My point here has a common thread with my two points above, but I’d like to think that the first point focuses on our respect for others, the second focuses on our approach to gaming, and this one focuses on our approach to narrative.

When we put a name on a mental illness, there will be a temptation to judge every choice a player makes in consideration of his character’s condition against the rubric of our expectations on the disease or disorder specified. Where above I discussed the problem of a named mental illness providing an excuse for a player to dump on his fellows, the opposite is also true–the other players may feel compelled to weigh in every time the player whose character has a mental illness touches on the mental illness as a factor in the character’s behavior and choices.

Sometimes, limitations foster creativity. Here, they only stifle a player.

Psychosis Because of That Which Should Not Be
The descent into madness is a well-tested narrative trope as well as a key feature of the Cthulhu Mythos–and I’d dare say that it was Call of Cthulhu that first broached the issue of sanity systems in games (but I haven’t done the research to verify).

But that’s not the only place that we see such a theme; there are many narratives–often horror–that center on such an idea. Losing the ability to discern reality from fantasy is an existential terror. Perhaps, though, that’s actually something separate from what’s going on in the Cthulhu-verse. There, it’s an exposure to a hidden reality that fragments the psyche. But that doesn’t mean that we can’t treat the results in a similar way, because the source of drama is the inability to differentiate between real and unreal (or meaningful and meaningless).

And this result, this slippery slope, this descent into a darkness in our discernment, has nothing to do with using shorthand diagnoses to act out a caricature of mental illness, nor does it need any name to work its drama and tension upon narrative.

The key here is having the player feel the same ambiguity and terrifying uncertainty that his character does–this lies wholly in the realm of the gamemaster, without need for reference to rules and dice. It begins subtly at first, with the GM giving a certain detail of a scene one way at first and differently later. Maybe it was an honest mistake, but maybe the player can’t trust everything the GM tells him. With a proper basis of trust between players and GM, the player will quickly come to understand that this is part of the story unfolding upon his character, not the GM being absent-minded or a jerk. As more important details get changed on the character, as he acts to devastating effect based on misperceptions fed to him by the GM (as the arbiter of the character’s sensory input), as the chain of events from a mistaken perception or belief becomes longer and longer before the player is able to realize that something isn’t right, the deeper the descent, the direr the desperation, the more doubtful the decisions made. This captures the experience of an unraveling mind without the need to diagnose schizophrenia or some other illness and then feel hidebound to its definitions. Furthermore, by not diagnosing anything, you increase the ambiguity about the character’s plight.

If necessary or useful, you can associate this system with some mechanic for measuring the abstract and relative loss of reliability in a character’s beliefs and perceptions–this can be done with a Fate-style stress track (though a use of Consequences may run into diagnostic issues), with a PbtA “countdown clock,” with a pool of points, or any other method used in RPGs to track condition, so long as the mechanics are used as a guide to how the GM portrays the character’s interaction with “reality” rather than a strict codification of behaviors or named psychoses.

It is popular now to have as many of the elements of a tabletop RPG as possible be  “player-facing.” This should not be, because that knowledge allows for extended metagaming and undercuts the effect of the distrust of the GM’s communications by giving the player something to compare or judge from. As I mentioned above, this requires a relationship of trust between player and GM and an agreement that everyone wants this to be an element of the game. The player needs to be willing to accept the discomfort and frustration that naturally accompanies this type of situation as a worthwhile experience (because it’s interesting from a “what if” standpoint, allows a safe exploration of an experience dangerous and terrifying to have in reality, or satisfies some other goal of the gamers coming to the table).

When It’s Not Me; It’s You
The horror game need not be the only genre in which mental illness may play a meaningful role in the game; nor does a descent into irrationality need to be the game’s focus, as it must surely be when the system described above is employed. How then, can we represent mental illnesses in a more balanced way that benefits the story but does not consume it? Particularly if, as I’ve argued above, any diagnosis of a mental illness is a Thing-Which-Ought-Not-Be-Named?

The answer, I think, is a relatively simple one. We focus on character beliefs that do not match with reality (as reality is generally accepted, I suppose). This could be a debunked conspiracy theory that a character unrelentingly clings to in spite of the evidence. It could be a wrong belief about some fact in the world, an impossible expectation, a delusion of self, a magnified fear, or a perceived relationship between things that anyone else would see as causally unrelated. These beliefs may be small ones that only rarely come up in the game, or they may be so fundamental that they almost always have some effect upon the character’s decisions.

If we focus on beliefs instead of behaviors and let the behaviors flow from the mistaken beliefs and perceptions, the character behavior will have a higher verisimilitude, greater fidelity in both dramatic interpretation and depiction of realistic characters and events. The risk of caricature remains if the beliefs in play are not carefully considered and crafted by the player(s) and GM, but even if the portrayal of the belief devolves into parody, that parody is farther divorced from any particular person who has been labeled as having a particular mental illness, somewhat blunting its offensiveness, at least.

This provides better guidance for the player than a set of strict “rules” of behavior to follow, is likelier to result in behavior more related to and helpful to the overall narrative of the game (or at least not obstructive thereto), and matches more with our experience of mental illness in others (at least mine).

Unless someone gives us a label to use or we fall into the game of armchair diagnosis of people who annoy or offend us (dangerous on many levels), we don’t experience other people as exemplars of particular disorders or diseases. We might call someone “crazy,” but in the colloquial and lay use of the term we mean exactly that the person acts in a manner we believe to be contrary to common sense, rationality, and the facts as we understand them to be, not that the person exhibits particular quantifiable markers that seem to indicate a particular differential diagnosis. We are better equipped to name a mistaken belief someone seems to have than to diagnose them, particularly when the illness is one of conscious and interior experience, not something plainly writ upon the body.

The focus on beliefs over expected behaviors also gives us a fuller view of the experience of mental illness. If you’ve watched The United States of Tara, you’ve seen at least one successful narrative that captures both the heartbreak and suffering involved in mental illness and the times where its effects are more lighthearted–perhaps even amusing. Likewise, centering our systems of “(in)sanity” in games on beliefs may allow us to more safely laugh at absurdity without laughing directly at a condition suffered by real, living people. That is my hope.

Corruption Systems and Sanity Systems Are Not the Same
In fantasy or otherwise “grimdark” settings, there is a tendency to have a system that represents the idea of “corruption,” though the meaning of that term is often ambiguous at best.

The term, I think, has its basis in the sense of “moral corruption,” as with the corrupting influence of Tolkien’s One Ring as a vessel of the corrupted and evil will of Sauron. Other roleplaying games and settings have used that term, but not necessarily the meaning. The roleplaying games for the Warhammer settings, for instance, typically have corruption systems. But these systems amalgamate an idea of moral corruption (usually, though, through the eyes of themselves corrupt societal structures) with the body horror of unwanted mutation (perhaps problematic for its symbolic portents for ideas of “purity”) and with the Cthulhuverse idea of a degradation of sanity and moral fiber that results from seeking out those Things-Which-Should-Not-Be!

I have numerous problems with conflating ideas of sanity and judgments of morality. On the one hand, there is a tendency going back at least as far as the 19th century, to call immorality or criminal activity a form of “insanity.” This dehumanizes those who commit criminal offenses, simultaneously insinuating that they cannot be held fully accountable for their choices because of mental illness and yet classifying all antisocial behavior as abhorrent and inhuman and thus allowing us to ignore the possibility that, under the right (wrong) circumstances, we might engage in just the same kind of behavior. Neither aspect of the argument is logical, philosophically or theologically sustainable, or even useful in a societal sense.

Perhaps I’m overthinking here (although I reject the existence of such a thing altogether), and I understand that some will respond, “Get over it; it’s just a game! What are you making such a big deal about?”

Regardless, both the would-be game designer and the aspiring theologian in me must protest the conflation of these ideas. If you want your game to have a conceit that exposure to certain things is damaging to the psyche, great; that’s what sanity systems are for.

If you want to have a system for the degradation of a character’s morality, fine, although my personal preference is that such ideas are a matter of roleplaying more than mechanics (though there are excellent ways to manipulate changes in character Aspects in Fate if you want a middle-ground).

If you want a system for body horror resulting from exposure to dark magics, that’s cool, too, if it suits your game and your players are on board.

But aggregating all three into a single system dilutes the effects of all of them, not to mention the philosophical problem of determining what the numbers mean for each of the influencing factors. Suffice to say, while mental illness may lead to immoral behavior, that behavior should probably be viewed in light of the mental illness as a mitigating factor in determining the extent of culpability, so morality and sanity systems should probably remain separate, unless you intend to make the argument that sanity and morality are closely intertwined, which I reject.

Conclusion
Like good fiction, good roleplaying allows us to explore difficult existential or experiential issues in a safe place where we can imagine the consequences that flow from particular troubling situations and then leave them at the table when we’re ready–or need–to walk away. Like other difficult issues–racism, religiously-motivated extremism and hatred, poverty, violence and all other manner of social strife–has a place in roleplaying, at least for those groups who want to struggle with “serious issues” over the course of their play (and not every gaming group, player, or campaign needs to). But when we choose to dive into such difficult topics that are also very real experiences for people who may or may not be sitting at the table with us, we have some moral responsibility, I think, to do so in a respectful and at least semi-realistic way. Not only is this good ethical roleplaying (which term now makes me want to think and expound more on the morality and ethics of roleplaying games), but without it we’re missing the point of including tough issues in our games at all.

When properly addresses, dealing with those tough issues in a roleplaying game opens up our eyes to things we may not have thought before, deepens our understanding, and increases our empathy for others. And that, in my mind, is roleplaying at its finest–when it entertains us, teaches us, crafts meaningful narrative and helps us to become better humans.

I’ve got a friend who is a gamer and fellow writer and who works professionally in raising awareness of, compassion for, and competency in dealing with mental illness. I’m going to ask her to at least comment on this post, if not write a follow-up (or perhaps rebuttal!) with her own ideas which, given her training and experience, likely have more weight than mine on this topic.