This interview is part of our Road to the IGF series. You can find the rest by clicking here.

Forgotten is a game about being someone afflicted with Alzheimer's, having you experience the challenges and confusion that come with this terrible disease.

Gamasutra spoke with the development team at Mutiny Games, learning about the personal experiences that fueled the game's creation, the research and emotional difficulties that come from creating a work on such upsetting subject matter, and the importance of capturing this perspective on Alzheimer's so that more people can understand and empathize.

An emotional experience

We’re Marlène Delrive, Jordy van Opstal, and Ryan Wright, three students from the IT University of Copenhagen in Denmark. Marlène was our creative lead and vision keeper who also made all of our 3D assets, Jordy was our lead programmer who implemented most of our game’s logic, and Ryan was our writer and designer who worked out a lot of the game’s interactions and pacing.

The original team for our school project consisted of five teammates, including a second programmer, Daniel Hansen, and a dedicated researcher, Iben Truelsen. Since then, the three of us decided to continue working on the game in coordination with the Danish Alzheimer’s Society (Alzheimerforeningen), and have spent our free time polishing as well as translating the game for a Danish audience.

Our programmer, Jordy, has previously worked on educational games. For Marlène and Ryan, Forgotten is their first completed video game project. Before this, we’ve only dabbled with Unity tutorials and small game prototyping from game jams and similar contexts.

Before studying game design, Ryan studied literature and Marlène studied Art History. We honestly think our humanities backgrounds helped focus our design process on the player’s emotional arc through the game, which was sort of the point from the start. Our favorite games tend to be smaller indie titles with a unique voice and a lot of emotionality, and we really wanted to make something that felt rich if we could, like Gone Home, What Remains of Edith Finch, That Dragon, Cancer - that kind of game experience.

Putting players in the patient's shoes

Both Marlène and Ryan have lost family members to Alzheimer’s and other forms of dementia. Marlène has had several experiences with the disease from family and close ones, so when she pitched the game concept to our intro design class, it came from a very personal place. After several years of dabbling with the subject in different creative media such as drawings and short stories, Marlène started wanting to make a game about having Alzheimer’s symptoms.

As a team, we believe games are a strong medium for viscerally putting players in a role. We imagined an experience that emulated the feeling of forgetting could be a strong representation of Alzheimer’s from the perspective of someone who has it. That’s a less common point of view in stories about dementia, from what we can tell. We often easily know how to relate to folks who are losing people to such a disease, but shy away in media depictions of dementia from putting people in the patient’s shoes. Forgotten came out of us getting curious about whether a walking simulator could viably depict such a perspective.

On the tools used to create Forgotten

We used Unity as our engine of choice, Blender for modeling the game’s 3D art, and Yarn to manage the dialogue and UI systems. Jordy also designed a modular tool we called the “Event Manager” so we could easily set up events and actions in the game. There was a bit of a technical learning curve for Ryan and Marlène, and we felt like we spent a lot of time re-doing work since Forgotten was really where we cut our teeth learning to use any development tools.

Invoking feelings of doubt and confusion

From the very beginning, we were more interested in invoking a feeling than telling a story or making anything too complicated, since being in that emotional place of confusion, frustration, and doubt was what we wanted players to sympathize with. We wanted to focus on a few symptoms of the disease, specifically memory loss, to create a subtle experience that didn’t beat the player over the head too much with what they were supposed to feel. That felt both more respectful to the player and of the sensitive content we were working with. This lead us to ask some interesting design questions like: how do you approximate the feeling of forgetfulness when you can’t actually force a player to forget what they’ve just done?

We tested how players felt with the simple ‘look away’ logic that one might normally find in horror games where objects in the world change position when you’re not looking at them. Before we had any plot or art in the game at all, we could tell from play tests that there was something fundamentally compelling and eerie about picking up an object, putting it down, and having it not be where you last left it.

From there, every decision we made (chapter structure, dialogue, even where we encouraged players to look) all revolved around pushing that feeling in different ways. We came up with our time lapse “blink” moments which signal more sudden shifts in time. Players blink and suddenly find themselves in the middle of conversations they didn’t start with NPCs that weren’t in the apartment moments ago.

We decided to focus on that feeling of confusion when experienced through the subtleties of an elder person’s life of daily routines. We dug deep into what we thought that experience must be like when you lose your sense of space and time, drifting through your day without quite knowing what to do, or what is happening. This also includes the social aspect of the disease - having a hard time communicating with others and how losing threads of a conversation might lead to social isolation from friends and family.

Being respectful to the subject matter

The first thing we realized almost immediately was that there is no meaningful simulator for what it’s like to have Alzheimer’s. There are professional simulations that can help caretakers in training manage disoriented people, and what it’s like to experience somewhat similar disorientation, but nothing that actually makes people feel what it’s like to have the particular intersection of dementia symptoms that make up Alzheimer’ disease.

As such, the biggest challenge we were conscious of was to strike a respectful tone around people’s experience with Alzheimer’s, and to make something that didn’t over-simplify or gamify the disease inappropriately. We actually threw out a few ideas that felt too puzzle-like for fear of exactly that reason.

We made the game as an expressive experiment while believing that it’s impossible to make a 1:1 simulation of what Alzheimer’s is like. That is not our interest either, but rather Forgotten is an interpretation of the emotional reality of having Alzheimer’s inspired by our own loved ones who we have lost this way. Did we succeed? That’s not really ours to decide, but we certainly did our best with these ethical issues in mind.

Another challenge as we explored the symptoms of forgetfulness and confusion was how to create the right kind of confusion. As we move things around behind the player’s back, we needed to borrow mechanics conventionally used in horror games without outright making something disorienting in a way that signaled “horror.” We wanted it to be subtle, gradually increasing in intensity as the symptoms grow worse over the course of the game.

At times before the game was finished, it definitely felt like we were making a horror game. We think the context we put these moments in, however, between our dialogue and setting, mitigates people thinking of these interactions as scary in the same way Silent Hill is scary. We’ve heard people talk about feeling dread, sadness, anxiety and such, but not ‘fear’ in the way we normally talk about fear in videogames. Those reactions always felt like success to us because we were so wary of making something that sensationalized Alzheimer’s.

On the research involved in creating Forgotten

While working on the game, we had a person on the team dedicated to researching Alzheimer’s. This included medical research, as well as searching for second- and first-hand accounts of the disease. The last one proved very hard to find, as the disease affects the person’s language and thoughts. We did, however, find a diary from a woman who wrote in it for several years while not realizing that she had Alzheimer’s. It gave us a unique insight into all the everyday ups and downs that she was experiencing, as simple tasks suddenly became hard for her to do without her knowing why, and her confusion over not remembering what she had done. This made us feel comfortable revolving the game around mundane interactions in an apartment (take your daily medicine, water your plant, etc.), as these really are the main sites of stress for folks experiencing early symptoms.

We also researched the many different symptoms of the disease, cooperating with Alzheimerforeningen to get their input and feedback, and what they found most important to include in the game. We showed our first prototype to them, which included a simple situation where the player has to make coffee but the cup is suddenly displaced. An Alzheimerforeningen representative told us in this meeting that making coffee could be a small existential battle every morning, which gave us confidence to include the recurring problem where players lose track of where they put their cup.

Something we found from our research was a test that is commonly used to diagnose Alzheimer’s, and that we decided to include in the game. In the test you have to draw two overlapping pentagons on a piece of paper. It sounds simple, but what we learned from multiple sources that Alzheimer’s patients often have trouble keeping the big-picture task of drawing the shape in mind while they’re in the middle of drawing. Recalling how precisely the line you’re in the middle of drawing connects back to the overall shape in your head is a cognitive task a little like patting your head and rubbing your belly; keeping track of your movement and perception over time becomes just plain difficult.

In the game, the player will find this test lying around, with shapes that will look more and more messy to portray how the disease is evolving. We borrowed images from real tests where you clearly see a difference from the very first try till the last one that has three random shapes with very blurry and unsure lines.

Doing something creative with your grief

It helped us a lot during production that we were already friends, and that we were very conscious of creating a safe space for us to share our personal experiences on the topic. Our very first meeting went with going around the table and sharing our experiences, and what we felt was important to include in this game. A lot of these experiences ended up as direct inspiration for scenes in the game, and pictures of our own family members are scattered around the apartment in the game for the player to gather. Ryan outright wrote certain phrases their grandmother (who passed from dementia) used to say into the protagonist’s dialogue, and some of the family photographs are of people in our lives who have been lost to the disease. Making something expressive together with those hard feelings was cathartic, though, and felt more empowering than devastating more often than not. It just felt nice to be able to do something creative with your grief if that makes sense.

Loneliness and confusion

We wanted players to go through the game with no expectations or goals and just explore the space. There are moments where there is nothing to do in the apartment, and all the player can do is to walk around, waiting for something to happen. It puts the player in the headspace of an elder person living their quiet life, and it also provides a sense of doubt and confusion when the player doesn’t know what to do, or when something suddenly changes around them.

The feeling of confusion was centered around that simple thought we can all relate to in a moment of distraction: “Wasn’t there a coffee cup on the kitchen counter? Or did I move it somewhere else?”. Loneliness was another important feeling, as you move around in this very quiet and empty space, and as family members pop in and out of your life, and whom you have trouble recognizing and talking with. The game is structured around a few days in this person’s life, and each day ends with the player trying to make sense of it all, collecting family pictures of the people they have seen and talked to, and gathering them in a family tree collage.

Helping players empathize through experience

Alzheimer’s is a very common disease that most people have experience with in some way or another. Many have a parent or grandparent suffering from it, or a partner. It’s such a devastating experience to witness someone you love lose themselves in this way, and it’s a natural reaction to distance yourself from that person because it’s too hard to see them in this state. But it’s so important to be there for that person, even when they are very sick and don’t recognize you anymore. They will still feel your presence, and your touch, and that feeling will stay with them, even if they won’t remember. Trying to get that perspective of how the person with the disease feels is crucial, even when it’s tough and scary. It’s such an existential fear to lose who you are, and that’s why it’s such a scary disease. Our memories, personalities, the way we talk, it all makes us who we are. 

It’s impossible to know exactly how people with Alzheimer’s experience the world. However, we hope that this game can give a better impression, and that it can provide players with a meaningful, emotional experience. The overwhelming responses we have received certainly prove that we have done something right. We have realized that the game has a powerful ability to make people open up and talk about their own experiences with the disease, which makes our independent game developers’ hearts melt with pride and happiness.

This game, an IGF 2020 finalist, is featured as part of the Independent Games Festival ceremony, which was streamed digitally this week and can be viewed on demand on GDC's YouTube channel.