University of Southern California Dissertations and Theses

Cards of Heart: a cozy role-playing card game for promoting mental health

(USC Thesis Other)

Cards of Heart: a cozy role-playing card game for promoting mental health

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content CARDS OF HEART
A COZY ROLE-PLAYING CARD GAME FOR PROMOTING MENTAL HEALTH
by
Marielle Brady
A Thesis Presented to the
FACULTY OF THE USC SCHOOL OF CINEMATIC ARTS
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF FINE ARTS
(INTERACTIVE MEDIA - GAMES & HEALTH)
May 2024
Copyright © 2024 Marielle Brady

Acknowledgements
First, I would like to thank the Cards of Heart team, including my team leads: Will
Alvarez, Lihao Chen, Jordan Hanes, Boston Moreland, Bryan Nguyen, Ruolin Tu, Justin Shin,
Yixia (Sherry) Xie, Christie Yip, and Jebby Zhang, and my team members: Saumya Awasthi,
Darcy Bergstein, Victoria Cruell, Yue Deng, Noah Elliot, Mingye (Jasmine) Fan, Ziqi (Andie)
Gao, Cindy Gao Liang, Daniel He, Juan Higuera, Shannon Kilbride, Willem Lent, Kezia Leung,
Yueqin (Amy) Li, Brittaney Mallory Smothers, Kristine Nguyen, Anik Panja, Jonan Pho,
Ashley Rodriguez, Teri Shim, Alexandria Sorenson, Helen Spight, Starling Tan, Christina
Wang, Wenqi (Ivy) Xu, Huidan Zheng, Yiteng Zhou, and Allena (Ena) Zhu. Cards of Heart
would not exist without all of you, and I’m so grateful for your thoughtfulness and passion
in bringing this project to life.
Thank you to the clinical psychologists and subject matter experts who provided
their valuable time and insights to the project, including Dr. Jeffery Newell, Dr. Elizabeth
Kilmer and the Take This team, and Joyce Tiemens. The perspectives offered helped me
hone the game’s mental health themes and messages, and it wouldn’t be nearly as
successful without you.
An especially huge thank you to Dr. Raffael Boccamazzo (Dr. B) for his willingness to
be an external advisor for this project and for bringing his seemingly boundless insights
and humor to every meeting. The game is so much better for it.
Thank you to Marientina Gotsis, who inspired me to pursue an interdisciplinary path
in games and health before I even came to USC and remained a guiding tour de force ever
since. I’ve learned so much from you as a researcher, scholar, and designer, and I’m
immensely grateful.
ii

Thank you to Sam Roberts, whose systems class gave me the initial confidence to
even think about creating a card game, and whose advice throughout the design process
allowed me to continuously hone the game to better express the mechanics of a real world
system.
Thank you to so many of the other faculty in the USC Games program, especially
Peter Brinson, Martzi Campos, Tracy Fullerton, Andreas Kratky, Marianne Krawczyk, Richard
Lemarchand, Laird Malamed, and Margaret Moser. Your guidance across all areas of game
design and development helped me successfully transition from a lab researcher to a game
designer, and I’m so grateful I had the opportunity to work with all of you.
Thank you to the Alfred P. Sloan Foundation, for providing funding to this project
throughout the 2023-2024 school year.
Thank you to Claire Hu and Laura Meng, who both gave me the opportunity to try
combining mental health and design as part of their own thesis projects. Also, thank you to
KB, who supported me and paved the way as a fellow games and health designer.
Thank you to my partner, Sam, who’s been with me every step of the way on this
journey, and who I’ve learned so much from. Your critical insights, willingness to be a
perpetual sounding board, and moral support helped me more than I can say. I’m so glad
that we got to be part of this journey together.
A huge, huge thank you to my entire thesis cohort- I couldn’t have asked for a better
group of people. You all are kind, caring, passionate about game design, and just plain fun
to be around! It’s been a joy to get to know and learn from each and every one of you.
And lastly, thank you to my mom, who has always been my rock and my inspiration. I
am constantly amazed by your unconditional love and support, and your tireless work as a
social worker and therapist inspired me to find my own path to support others’ mental
health. I wouldn’t be where I am today without you.
iii

Table of Contents
Acknowledgements ………………………………………………………………………………………………………………………………………… ii
List of Tables ……………………………………………………………………………………………………………………………………………………… v
List of Figures …………………………………………………………………………………………………………………………………………………… vi
Abstract …………………………………………………………………………………………………………………………………………………………….. vii
Prologue: Positionality ……………………………………………………………………………………………………………………………………. 1
Chapter 1: Introduction …………………………………………………………………………………………………………………………………. 3
1.1 Young Adult Mental Health and the Need for More Resources…………………………………………. 3
1.2 Digital Games and Mental Health Literacy………………………………………………………………………………… 4
1.3 The Thesis Question for Cards of Heart ……………………………………………………………………………………. 5
Chapter 2: The Project …………………………………………………………………………………………………………………………………… 6
2.1 Game Summary …………………………………………………………………………………………………………………………………… 6
2.2 The Core Game Loop…………………………………………………………………………………………………………………………. 7
2.3 Experience Goal, Design Pillars, and Key Features…………………………………………………………………10
Chapter 3: Inspiration and Ideation …………………………………………………………………………………………………………..13
3.1 Determining Genre: Prior Art and Inspiration ………………………………………………………………………… 13
3.2 Translating Science into a Game System ………………………………………………………………………………… 19
3.3 Balancing Systems with Narrative ……………………………………………………………………………………………. 23
3.4 Cozy Fantasy: Serious Content with an Approachable Aesthetic ………………………………… 30
Chapter 4: Production and Development ……………………………………………………………………………………………… 33
4.1 Recruitment and Managing the Team ……………………………………………………………………………………… 33
4.2 Collaboration with Subject Matter Experts…………………………………………………………………………….. 34
4.3 Playtesting Methodology and Insights ……………………………………………………………………………………. 37
Chapter 5: Impact…………………………………………….……………………………………………………………………………………………..40
5.1 Overall Response to the Game and Relationship to Amalia …………………………………………….. 40
5.2 Representation of Mental Health ………………………………………………………………………………………………. 40
5.3 Formal Playtesting Process …………………………………………………………………………………………………………. 41
Chapter 6: Conclusion …………………………………………………………………………………………………………………………………..43
Bibliography …………………………………………………………………………………………………………………………………………………….. 45
iv

List of Tables
1 A list of abilities Amalia has in Cards of Heart ……………………………………………………………………….24
v

List of Figures
1 Trends in publications on “commercial video games'' for mental health……………………... 5
2 The core loop of Cards of Heart ……………………………………………………………………………………………………. 7
3 An example of exploration in Cards of Heart……………………………………………………………………………. 8
4 An example of a card………………………………………………………………………………………………………………………… 9
5 An example of a card battle in Cards of Heart…………………………………………………………………………. 9
6 An example of Amalia processing a memory…………………………………………………………………………. 10
7 Screenshots of Gris and Celeste……………………………………………………………………………………………………13
8 An early prototype of The Garden, my initial thesis idea……………………………………………………..14
9 Screenshots of Signs of the Sojourner and Potionomics ……………………………………………………15
10 Card decks used in therapeutic practices…………………………………………………………………………………16
11 One of the earliest paper prototypes of Cards of Heart……………………………………………………….18
12 A win probability model adapted from Characteristics of Games……………………………………21
13 A comparison of narrative arcs in the game……………………………………………………………………………26
14 Mental health resources provided to the team through Discord……………………………………..32
15 The case conceptualization for Amalia………………………………………………………………………………………36
vi

Abstract
This paper discusses the potential of digital games for addressing mental health
literacy and awareness through the lens of the thesis game Cards of Heart. It begins with a
brief survey of young adult mental health and current digital interventions, followed by a
brief description of Cards of Heart, its experience goal, and its major design pillars. The
paper outlines the design methodology used to create the genre, systems, narrative, and
aesthetics of the game through the integration of neuropsychology concepts and advice
from subject matter experts. The paper then transitions from design to development,
providing insights from collaborating with team members, subject matter experts, and
playtesters. Finally, the paper discusses the impact of the game and future directions.
vii

Prologue: Positionality
Before I begin, I would like to describe my own positionality in pursuing the topic of
mental health. Personally, I have a complicated relationship with mental health and
therapeutic techniques; as an only child in a difficult family situation, I faced a lot of
extreme stress growing up, especially in middle and high school, but since my mother is a
social worker and psychologist I also learned therapeutic techniques and coping strategies
at an early age. My mother’s work, and my own experiences, inspired me to pursue
neuropsychology: I knew firsthand that mental health challenges were very real, and very
serious, but I also knew there were ways to face them.
In undergrad I studied biology and neuroscience, as I wanted to learn more about
the interplay between the mind and the brain. But at the same time, I took a class on game
design for impact, which changed my perspective on what “games” could be for. This
resonated with me on a deeply personal level, as playing video games was one of my own
favorite coping strategies, and it was exciting to imagine games could be specifically
designed for this purpose. As I saw how many of my peers struggled with similar feelings of
anxiety, depression, and loneliness, I wanted to meet them where they were at and have
conversations about mental health through a medium we shared. The desire to combine
“video games” and “mental health” led me to Marientina Gotsis, the Creative Media and
Behavioral Health Center, and my degree at USC.
Throughout creating this game, I’ve been humbled to work with a team who has
been open about their own mental health and experiences with therapy. Made up of mostly
undergraduate and graduate college students, I acknowledge that the team is, essentially,
members of the target audience seeking to create the kind of experiences they would want
to see for themselves. I’m grateful for the conversations we’ve had while crafting every
1

element of the game, from the narrative, to the systems, the art, the UI, the audio, and
more, and for their courage to integrate those personal experiences into the game. The
passion of my team members has shown me that there are many people like me: people
who are currently navigating their own mental health challenges and want to help others
do the same, and who believe we can do it through our favorite medium: games.
2

Chapter 1: Introduction
1.1 Young Adult Mental Health and the Need for More Resources
Mental health is a growing concern for young adults in today’s society. In 2021, there were
an estimated 57.8 million adults 18 or older in the United States living with a mental illness–
over one in five– and young adults aged 18-25 had the highest prevalence of mental,
behavioral, and emotional disorders of any age group (National Institute of Mental Health,
2023). College students are also subject to this trend; according to the ACHA National
College Health Assessment, as of fall 2023, 21.3% of college students reported serious
psychological distress and 78% reported experiencing moderate to high stress within the
last 30 days (American College Health Association, 2024). In addition to these high rates of
mental health challenges, college students also face many barriers to receiving treatment,
such as public and self-stigmatizing attitudes towards mental illness, worries about
confidentiality and trust, difficulty identifying the symptoms of mental illness, and a general
lack of knowledge about mental health services (Gulliver et al., 2010).
However, there are several positive factors that have been shown to facilitate
help-seeking behavior and care, including mental health literacy, or “knowledge and beliefs
about mental disorders which aid their recognition, management or prevention” (Jorm et
al., 1997, p. 182). Mental health literacy isn’t just important for those diagnosed with mental
illness, as it also includes “knowledge of effective self-help strategies for mild-to-moderate
problems” (Kutcher et al., 2016) that can be beneficial to anyone (Worsley et al., 2022;
Morton et al., 2017; National Institute of Mental Health, 2022). Many young adults
experience symptoms of multiple mental health conditions without being clinically
diagnosed, and mental health literacy can have preventative effects that help them
increase their resilience and general wellbeing (Arango et al., 2018).
3

1.2 Digital Games and Mental Health Literacy
Digital games have been shown to be a promising new alternative for delivering mental
health education, awareness, and treatment. Games can be more widely accessible and
affordable than other forms of care (Webb et al., 2017), create an atmosphere of privacy and
confidentiality (Liverpool et al., 2020), and intrinsically motivate players to participate (Birk
and Mandryk, 2016). Interventions like Kognito’s At Risk for College Students (Coleman et
al., 2019) and SPARX (Fleming et al., 2021) have been designed specifically as training tools
for social-emotional learning and mental health literacy for college students and young
adults, but these interventions have also been criticized for their lack of polish and
aesthetics compared to commercially available games (Garrido et al., 2019). On the other
hand, more commercial digital games are being used to promote mental health (Figure 1),
but these games, while entertaining, are largely not designed with mental health principles
in mind. Across the board, current literature advocates for more studies- and more gamesexploring the potential of interactive media for mental health (Brady, 2022), and there is
still huge untapped potential for games that are both entertaining and promote mental
health literacy and awareness.
4

Figure 1. Trends in publications on “commercial video games'' for mental health. Vertical
axis shows the number of articles on “commercial video games” for mental health by
publication year (n = 30). Horizontal axis shows the past 20 years to emphasize publication
patterns (Brady, 2022).
1.3 The Thesis Question for Cards of Heart
Coming from a background in neuroscience and psychology, I’m fascinated by the creative
ways in which games can be used to promote mental health. Drawing on my previous work
at USC and my personal experiences with games, for my thesis I asked the following
question: how can a videogame communicate mental health concepts grounded in
neuropsychology, and will such a game be appealing to a broad audience? This paper is
an exploration of this central question, detailing the game itself (Cards of Heart), the
scientific and creative inspirations that led to the game’s design, the process of creating
the game and insights from its production, and a description and analysis of testing the
impact of the game.
5

Chapter 2: The Project
2.1 Game Summary
Cards of Heart is a cozy digital card game + top-down RPG about a young woman’s
journey to confront her mental health struggles against her inner “Shadows.” The game
features Amalia, a young woman living in a small fantasy town, who experiences symptoms
of depression and anxiety after losing her best friend. Her plea for help is answered by a
light spirit named Ljos, who gives Amalia the ability to generate cards of light from her daily
activities that she can use to confront her Shadows. With Ljos’s guidance, Amalia must use
this power to manage the Shadows, process her grief, and learn how to move forward while
acknowledging the pain of her past.
Drawing from both neuropsychology scholarship and consultation with clinical
psychologists, Amalia’s abilities are derived from techniques used in Cognitive Behavioral
Therapy (CBT) (Beck 2021), Dialectical Behavioral Therapy (DBT) (Linehan 2015), and
Acceptance and Commitment Therapy (ACT) (Dindo et al., 2017). By developing strategies
utilizing skills like self-affirmations and mindfulness practices within the game, the player is
encouraged to reflect on how these strategies could be used in real life. The mechanics of
the card system are woven together with the triumphs and setbacks of Amalia’s personal
journey, which enables the player to explore how a therapist (in this case, Ljos) can help an
individual learn and practice these skills to manage and move through mental health
challenges. In the end, Amalia learns that facing her inner Shadows isn’t about defeating
them, but living with them, encouraging the player to see “mental health” as an ongoing
process utilizing tools like those found in the game and continue learning about mental
health and therapeutic techniques long after they’ve put the game down.
6

The target audience of the game is young adults who experience mental health
challenges: both those who don’t have the vocabulary to describe their struggles or feel
stigmatized if they express them, and those who have more experience with mental health
literacy (and/or who have gone to therapy themselves) who want more ways to adequately
express their experiences to their peers.
2.2 The Core Game Loop
The core loop of the game is as follows:
Figure 2. The core loop of Cards of Heart.
Players explore the town of Respite to help Amalia confront the Shadows that
prevent her from moving forward with her life. Through a two-phase core loop, players
engage in Amalia’s daily life to create cards (Figure 3, 4), then use those cards to challenge
Shadows that obstruct parts of the map (Figure 5). For example, when Amalia fails at
7

preparing a favorite meal, she creates the card “I enjoy cooking, even if I mess up
sometimes,” which can be used to reduce the strength of a Shadow that focuses on her
failures. Amalia also creates cards with self-affirmations to “buff” her hope, learns
mindfulness techniques to dispel disruptions (like brain fog) caused by her anxiety, and
calls friends to support her. By weakening the Shadows, Amalia processes memories with
Ljos that help her accept the events that she is still working to heal from (Figure 6); if she
fails, she is able to return to the town and recover before trying again (taking time to
recover is the only punishment for losing). Over time, Amalia gains new abilities and
insights into the Shadows and herself that allow her to process her grief and learn how to
move forward while acknowledging her past.
Over the course of playing the game, players feel the heartache and hope of
encountering and overcoming mental health challenges in a psychotherapeutic context
while exploring concepts like self-acceptance, resilience, and the importance of social
connections.
Figure 3. An example of exploration in Cards of Heart. Amalia explores the town of Respite
and talks to other townspeople to complete tasks and obtain cards, which represent her
positive experiences and learnings.
8

Figure 4. An example of a card. Card effects range from reducing the Shadow’s
Persistence (health), to boosting Amalia’s Self Beliefs (stats).
Figure 5. An example of a card battle in Cards of Heart. Amalia (left) confronts her
Shadows (right), which play cards with statements based on cognitive distortions.
9

Figure 6. An example of Amalia processing a memory. Visual effects during the memories
show how the same memory can be perceived differently based on a person’s current
emotions and focus.
2.3 Experience Goal, Design Pillars, and Key Features
The experience goal of the project is to promote mental health awareness for challenges
like symptoms of depression and anxiety and increase mental health literacy of therapeutic
techniques for young adults, including those who play video games (especially card games
or role-playing games). To accomplish this goal effectively, I settled on four major design
pillars to guide the experience.
The first design pillar is approachability for a wide audience. I wanted the game’s
atmosphere to create an appealing and safe environment for players to engage with
serious topics, capturing the attention of game players who would otherwise shy away
from playing a “mental health game.”
10

The second design pillar was to emphasize concepts over jargon. When learning
about or teaching “mental health,” there’s a temptation to get caught in the weeds of
terminology, which can be confusing, dry for non-clinicians, and not feel representative of
a person’s experience. However, research has shown that learning is more effective when
players don’t realize that they’re learning, as players who sense the “edutainment” of a
game may refuse to play it, especially if the game deals with mental health (Fleming et al.,
2019). I wanted to weave the game’s mental health themes naturally into the mechanics
and narrative instead of focusing on labels like “depression” or “cognitive distortions,”
allowing players to engage with these concepts without stigma or jargon getting in the way
and hopefully learn new skills without even realizing it.
The third design pillar was to depict mental health in the formal, dramatic, and
dynamic elements of the game, not just the story (Fullerton, 2019). Mental health can be
extremely difficult to describe in words, and I wanted the game to represent mental health
challenges verbally in the narrative, but also nonverbally through the game’s aesthetics
and the dynamics of the gameplay systems. The hope was that these different depictions
would help capture otherwise indescribable feelings, and that players would point to
moments in the game and say “yeah, it feels like that.”
The fourth design pillar was using the game to create a space for conversation. I
wanted players with varying levels of familiarity with mental health concepts, from a
variety of different backgrounds, to have the shared experience of playing the game open
the door to discussing mental health. While the game does present different therapeutic
tools and techniques, it’s not intended to be a resource guide or an exhaustive list. Instead,
the game is intended to be a first step, encouraging players to learn more and talk to each
other after playing the game, leading to increased understanding and support across the
game’s community.
11

These design pillars are infused into the game through several key features:
● A card system that is simple, yet robust- even people not familiar with card games
can play it, but complex enough that it represents the “system” of mental health
with enough accuracy to not feel inauthentic.
● A narrative featuring grief and acceptance that counterbalances the logical card
system and shows the players that not everything can be solved neatly.
● A cozy fantasy aesthetic that wraps the mental health concepts in an
approachable, safe, inviting atmosphere.
● Elements grounded in research on different therapeutic techniques, including
Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and
Acceptance and Commitment Therapy (ACT).
12

Chapter 3: Inspiration and Ideation
3.1 Determining Genre: Prior Art and Inspiration
Platformers and Mental Health
As I began thinking about how to represent mental health in a video game in the
January of my second year, I started by asking: how had other video games done it? I
immediately gravitated towards Gris (Nomada Studio, 2018) and Celeste (Maddy Makes
Games, 2018) (Figure 7), commercial games I knew had been praised for their respectful
and authentic depictions of mental health (Trama, 2021; McColl, 2021). I appreciated how
mental health was embodied in the mechanics of each game, from the “ground pound” of
anger in Gris to the beautiful stillness of balancing a feather in Celeste. To me, the harmony
between narrative and mechanics was a key component of the impact of both games, and I
wanted to create a game with a narrative centered on mental health struggles as well as
mechanics and aesthetics that underscored mental health themes and strategies.
Figure 7. Screenshots of Gris by Nomada Studio (left) and Celeste by indie developer
Maddy Makes Games (right). Both games use platforming mechanics as a means for
conveying mental health concepts.
Interestingly, both of these games use platforming mechanics, and that’s where I
started as well. My initial thesis concept, The Garden, was a 2D platformer where the player
13

would grow vines/cut back thorns to help a small character traverse a garden, modeling
concepts of self exploration, self care, and, ultimately acceptance of negative experiences.
I made early prototypes of this idea for Margaret Moser’s 542 class (Figure 8), but in making
the mechanics I realized how much the game would rely on its visuals and controls being
perfectly fine-tuned, and I didn’t have expertise in either. In addition, the success of both
Gris and Celeste actually steered me away from wanting to make a platformer, since it
seemed like platforming mechanics had already proven to work well with mental health
concepts. I continued to pursue this idea despite my growing hesitations, but at the same
time another idea began brewing: a mental health card game.
Figure 8. An early prototype of The Garden, my initial thesis idea.
Cognitive Distortions and Card Games
When designing for Hedge Hug (Hu, 2021) my first year in graduate school, I became
interested in depicting cognitive distortions in a video game. Cognitive distortions are
irrational, usually negative thoughts that can cause someone to see the world through a
14

distorted lens (Grinspoon, 2022); for example, “I always mess things up” or “it’s my fault my
team lost.” Therapeutic traditions like cognitive behavioral therapy (CBT) often focus on
identifying these thought patterns and learning how to manage them (Beck, 2021). In some
cases, a patient is encouraged to practice “cognitive defusion,” separating these negative
thoughts from themself and, in some cases, even having a dialogue with them examining
whether they should be listened to (Cognitive Behavioral Therapy Los Angeles, 2022).
The idea of creating a dialogue between oneself and negative thoughts reminded
me of the play between cards and counter cards. Digital games like Signs of the Sojourner
(Echodog Games, 2020) and Potionomics (Voracious Games, 2022) use card battling
mechanics to represent the back-and-forth nature of conversations (Figure 9), and
Potionomics even includes a “stress card system” where the player is saddled with cards
that cause them to lose if Sylvia becomes overstressed from haggling. Mechanics from
both games, including the chaining of symbols from Signs of the Sojourner and the stress
cards of Potionomics, would become inspirations for mechanics in Cards of Heart.
Figure 9. Screenshots of Signs of the Sojourner by Echodog Games (left) and
Potionomics by Voracious Games (right). Both games use card battles as a method of
dialogue between characters, which was a major influence for Cards of Heart.
Curious, I investigated how cards had been used with therapies before and found
several resources, like the Dialectical Behavior Therapy Skills Flash Cards (McCandless &
15

Johnston, n.d.), the CBT Deck by Seth Gillihan (2019), and the AMBIT Integrative Measure
(AIM) cards (Anna Freud Centre) (Figure 10). In these examples, the cards are used to: 1)
provide bite-sized mental health information, like flashcards, 2) create prompts for daily
practice, or 3) help a patient organize and sort their mental health strengths and
weaknesses. However, none of these examples actually use the cards as part of a game. I
saw an opportunity to combine the organizational/piecemeal nature of cards for mental
health with a larger system like those found in conversational card games. However, I still
wasn’t sure: in my system, what would the cards say?
Figure 10. Card decks used in therapeutic practices, including DBT Skills Flash
Cards (left), Seth Gillihan’s CBT Deck (upper middle), and the AIM Cards from the Anna
Freud Centre (right). These cards are used to help patients, but none of them are part of a
“card game.”
16

Capturing Memories
The last piece of the puzzle came together through a personal experience with one
of my cohortmates. Overwhelmed by the stress of coming up with a thesis idea, they
exclaimed in frustration that they weren’t happy with any of the work they had done in the
program so far. When I said that I liked their previous projects, they dismissed my
compliments as “just being nice.” But when I echoed back that they had told me
themselves in the past that they were proud of their work, the person paused and began to
break out of their spiral of negativity. This was a breakthrough moment for me, as I saw
firsthand the power of recalling one’s own words and feelings. It simultaneously reminded
me of two things: the therapeutic technique of positive affect journaling, where capturing
positive memories and emotions by writing them down can be a powerful tool to help an
individual remember these events when they’re feeling down (Smyth et al., 2018), and the
capturing mechanic of one of my favorite franchises, Pokémon (Nintendo, 1996-2022).
Rather than a single large journal, I thought of turning positive memories into bite-sized
cards that the player would gain from interacting with the world. Thus, the core loop idea
was born: “what if the player collected cards like Pokémon, then used them in card battles
against cognitive distortions?”
Comparing Prototypes and a Pivot
As I was becoming more and more excited about my new card battle/RPG idea, I was
still determined to pursue The Garden until an unexpected explosion of my computer
before the 542 midterm prompted me to pivot and create a paper prototype of the card
system I was playing around with in my head (Figure 11). I reasoned that if the core idea
wasn’t working or resonating with playtesters, I could commit to The Garden with
17

confidence, and if the card system did work, it would be a solid foundation on which to build
the rest of the game.
Figure 11. One of the earliest paper prototypes of Cards of Heart.
To my surprise, playtesters were immediately drawn to the card game format as a
new way of thinking about mental health that they hadn’t seen before. One playtester with
a history of mental health challenges stated that they appreciated seeing the direct
statements on the cards, saying it felt like a “relief” to see the words of the Shadows out
loud and validated. Torn between the card game and The Garden, I put it to a class votewhich would you rather play?- to which over 75% of the class voted for the card game. I
also spoke with Dr. Jeffery Newell, a psychologist working with USC Student Counseling,
who said that he had observed in his practice that more logical approaches to mental
health like cognitive behavioral therapy (CBT) tended to work better with students in more
18

logic-focused disciplines like computer science and engineering (personal communication,
March 7, 2023). Comparing the two genres, he hypothesized that a systems approach could
be an especially effective way of communicating mental health concepts to students in
these disciplines, or students who play video games in general. In light of the positive
response to the card game, I made the difficult decision to let go of the work I’d done on The
Garden and focus on the card game idea moving forward.
I then considered whether I should transform the game into a digital format or stick
with an analog, tactile card system. On the one hand, I could imagine a physical card game
for clinical use, with blank cards that could be filled out by a player with the prompting of a
therapist (both the Shadow’s statements and the player’s cards); on the other, I imagined a
digital game with pre-filled out cards following the story of a particular character. I decided
to opt for the digital game for two reasons: 1) a digital game could reach a much broader
audience through ease of distribution, and 2) considering the extensive amount of
codesign that would be required for the game to be useful in a clinical setting, this idea
seemed to be out of scope for a year-long project.
3.2 Translating Science into a Game System
With the decision on genre made, I focused on the dynamics and elements of the card
system, since these mechanics would form the backbone of the play experience.
Determining Broad System Dynamics
While I knew that I wanted the system to broadly depict “a dialogue between oneself
and cognitive distortions through a card based system,” I turned to neuropsychology
literature to help me determine its concrete mechanics. In particular, I was inspired by the
19

paper “A Unified Model of Depression: Integrating Clinical, Cognitive, Biological, and
Evolutionary Perspectives” by Aaron Beck and Keith Bredemeier (2016). In this paper, Beck
and Bredemeier argue that depression can be understood as a maladaptive evolutionary
system that was originally intended to help us cope with losses outside of our control, such
as rejection by a loved one, social isolation or exclusion, the loss of a child, or the loss of
productivity. However, this “depression program” can go too far, creating a dysfunctional,
self-perpetuating feedback loop that affects a person’s schemas about their self-image,
image of the world, and expectations of the future. While it can be difficult to stop this
program once it’s begun, the paper also suggests that certain therapeutic techniques may
be useful as solutions, such as effective actions that directly conflict with the belief of
being incapable and social support.
The way this paper describes “the depression program” immediately made me think
of a computer algorithm and the systems dynamics I’d learned about in CTIN 412 with Sam
Roberts. Translating the dynamics of facing cognitive distortions to my system, I wanted
the Shadow to attempt to establish a positive feedback loop that would lead Amalia to
become overwhelmed, and the player’s goal would be to interrupt this loop using the cards
and techniques they had available. Thus, the game would be about reversing the Shadow’s
“programs” and establishing a positive feedback loop of the player’s own. Using George
Elias et al.’s model of win probabilities from Characteristics of Games, I wanted the
beginning of the game to have the player and the Shadow relatively balanced, with the
outcome uncertain, until either the player or the Shadow is able to establish their feedback
loop and lead to a relatively quick victory (Figure 12). This would represent both how quickly
a “downward spiral” can happen once a cognitive distortion takes hold and how someone
can get “on a roll” once they begin to use tools to manage their stress.
20

Figure 12. A win probability model adapted from Characteristics of Games by Elias
et al. (2020) showing an oscillating probability for both characters until a threshold is
reached, leading to a win for one character and loss for the other.
While the player’s broad goal would be to disrupt the Shadow’s program, I also
wanted the player to have the flexibility to determine what specific strategies worked best
for them and form a personal connection to their deck. For this, I took inspiration from Erin
Reynolds’ thesis project Nevermind, which uses biofeedback to encourage the player to
reduce their anxiety. In her thesis paper (2012), she describes the philosophy of her game
as:
...Nevermind is not built as a self help program that guides the player on how to
handle stress in a didactic manner. Rather, it leads the player to personally discover
how to manage his own unique stress triggers– providing plenty of opportunities to
practice, refine, and habitually employ these healthy coping strategies both in and
out of the Game. (p. 9)
21

Nevermind demonstrated that a game could be educational by focusing on the outcome
rather than being prescriptive and telling the player what to do in specific circumstances.
This fit with a conversation I had with clinical psychologist Dr. Elizabeth Kilmer, who
described how in her practice she was less concerned with teaching her clients every
possible coping strategy, instead opting to focus on a few strategies and practice using
them to manage a variety of situations (personal communication, April 11, 2023). I wanted
to model this dynamic within the system of the game, giving the player an initial slate of
strategic options to choose from, then the ability to specialize and practice with the
strategy that works for them. A card system seemed like the perfect setup for flexibility:
rather than suggesting “one right way” to challenge Amalia’s Shadows, I wanted to
emphasize that if the player could defeat the Shadow in question, their strategy was viable.
Establishing the Concrete Rules of the System
With the broad strokes of the system dynamics in mind, I then created the game’s
elements, starting with the resources the player would manage in the system. Beck and
Bredemeier refer to the “cognitive triad,” which includes “self-image (lovable vs. unlovable),
image of the world (friendly vs. unfriendly, accepting vs. rejecting), and expectations of the
future (hopeful vs. hopeless)” (2016, p. 597). Instead of asking the player to manage the
main character’s “health,” I decided to create three resources based on this cognitive triad
that the player would have to manage, but would also serve as their source of strength.
These resources became Amalia’s “Self Beliefs” which, while not a perfect match, were
based on beliefs about herself (empowerment), beliefs about the future (hope), and beliefs
about others (connectedness). If any of these three Self Beliefs reached zero, Amalia would
become overwhelmed and have to step back from the confrontation, taking time for self
care and recovery before trying again. In contrast, the Shadow would have one stat,
22

Persistence, that indicates how much it persists in Amalia’s mind. By reducing the
Shadow’s Persistence to zero, it wouldn’t “die,” but fade for the moment, indicating that the
Shadows aren’t meant to be defeated but repeatedly managed.
I then drew on a variety of therapeutic sources to determine the final set of abilities
Amalia would have in the game (Table 1). These abilities were sorted according to the Self
Belief they were most aligned with: Empowerment (Amalia’s ability to act in the moment)
included most of her ways to deal damage to the Shadow’s Persistence, while Hope
(Amalia’s ability to act in the future) included ways to heal or cause future damage to the
Shadow’s Persistence. Connectedness (Amalia’s ability to lean on her social supports) was
still a bit of a mystery to me, but eventually these cards would include buffs and debuffs
that made her confrontations easier. In addition, Amalia had a suite of techniques that
focused on her overall hand composition rather than the individual cards she could play;
within the metaphor of the game, if the cards represented Amalia’s thoughts, her hand
represented her general mental state.
23

Strategy/
Technique Name
In-Game Example Therapeutic
Analogue
Sources
Healing Amalia heals herself using
a card
Positive affirmation Critcher et al. (2010);
Sherman et al. (2021)
Countering Amalia plays a card
countering the Shadow’s
statements
Counterexamples,
cognitive
restructuring
Beck & Bredemeier
(2016); Beck (2021)
Reducing the
Shadow’s
Persistence
Amalia plays a card with an
example of a positive
experience to weaken the
Shadow’s influence
Cognitive
Restructuring,
Examples of
effective action
Beck & Bredemeier
(2016); Beck (2021)
Deep Breathing Amalia breathes deeply,
dispelling debuffs caused
by the Shadow
Centering, breathing
techniques
Fincham et al. (2023)
Let it Pass Amalia selects up to two
cards in her hand to
acknowledge and let go of
Mindfulness,
decentering
Ma & Siu (2020)
Call a Friend Amalia asks one of her
friends for help, adding an
additional card to her hand
Social supports Beck & Bredemeier
(2016)
Clear Mindedness Amalia calms herself
through petting a dog
Pet therapy/animal
companionship
Grajfoner et al. (2017)
Chain of Thought Amalia plays cards
associated with the same
hobby in succession
Leisure coping
strategies,
activity/habit
associations
Iwasaki (2001),
Nimrod et al. (2012)
Connectedness
buffs/debuffs
Amalia plays a card derived
from her relationships with
other people that enhances
her own abilities or reduces
the abilities of the Shadow
Social
connectedness as a
form of resilience
Nitschke et al. (2020)
Table 1. A list of abilities Amalia has in Cards of Heart, with corresponding examples
and sources for their bases as therapeutic techniques.
24

3.3 Balancing Systems with Narrative
Therapeutic traditions like cognitive behavioral therapy (CBT) lend themselves well to a
logical, rigid systems approach, but real-world mental health requires nuance and flexibility.
In addition, rich narrative elements have been shown to enhance learning and engagement
in educational games, as it can provide context and meaning to the information (Jemmali
et al., 2018). Bearing in mind these benefits, after getting the card system working, I wanted
to construct a narrative that would highlight skills outside the limits of the card game and
enrich engagement with the game’s mental health themes.
Who is the Player?
Because the card system is based on the player utilizing memories/events from
daily life, the statements for the cards (and the Shadows) had to come from somewhere.
But would it be the player themself, or a predetermined character? Narrative
psychotherapies, including talking about fictional characters and stories a person identifies
with, can be a powerful therapeutic tool for allowing one to open up and learn more about
themself (Levitt et al., 2009). I observed this phenomenon firsthand in my previous work on
Hedge Hug (2021) and Blossom (2022), thesis projects by Claire Hu and Laura Meng,
respectively: in both cases, stories of social anxiety, bullying, and therapy were told
through the journey of a likable yet struggling protagonist. I was fascinated by how readily
players related to the stories of Emma and Aspen, spontaneously offering how they’d
experienced similar struggles in their own lives without being prompted at all. With a
sensitive topic like mental health, directly asking the player to “think about their mental
health” in a video game could cause discomfort or even confusion, especially in players
with less mental health literacy. However, by observing a character who models a
therapeutic journey, the player could be invited to reflect on their own mental health
25

without the need for explicit prompting. I decided to follow in their footsteps and craft a
character for Cards of Heart, who would eventually become Amalia.
Creating a Character with a Therapeutic Journey
As the character of Amalia began to take shape, the key beats and elements of her
story (Figure 13a) were derived from speaking with clinical psychologists and students who
had attended therapy to identify key moments in the “narrative arc” of therapy (Figure 13b).
Figure 13. A comparison of narrative arcs in the game. (a) shows a map of the
narrative arc of Amalia’s story, while (b) shows a narrative arc constructed from major
beats of therapeutic experiences, derived from talking to clinical psychologists and
students who had attended therapy.
26

Some of these major beats included:
1. The breakdown of previous coping strategies. Therapist Joyce Tiemens
described that often in her practice, before beginning therapy, a client’s
strategies would have worked “well enough” that they were able to get by
without seeking help (personal communication, December 2023). However,
there was often a “deconstruction” of previous strategies that had to happen,
along with an acknowledgement of the problem, before the commitment to
therapy could start in earnest. In Amalia’s story, her coping strategies fall
apart when she encounters the Shadows, and she can only begin her journey
after she acknowledges that something has to change.
2. The setback. When asked about significant stumbling blocks in therapy,
several students on my team said that recognizing that they weren’t going to
“fix” their problems by going to therapy was a difficult lesson to learn. In
Amalia’s story, the realization that she will never be rid of the Shadows is the
climax of her journey, leading to a moment of crisis before she begins to
accept for herself what her companion has said all along: that her journey
isn’t about fighting the Shadows, but learning how to manage them.
3. Resilience and progress. Rather than seeing resilience as a form of rigid
endurance, Amalia’s journey of ups and downs shows resilience as a way of
recovering homeostasis and returning to baseline (Waugh and Sali, 2023).
After her crisis moment, the coping strategies Amalia has learned through
her journey allow her to move forward much more quickly than she could at
the beginning of the game, modeling a cyclical journey of continuous
advances and setbacks rather than linear progress.
27

Another key component of modeling a therapeutic journey was the inclusion of a
therapist character, as Beck and Bredemeier note: “The engagement with the therapist
may be very powerful and in itself help to modify thoughts of worthlessness, helplessness,
and hopelessness that keep the depressive program going” (2016, p. 609). Ljos, Amalia’s
light spirit guide, was designed to be a companion who would interact with Amalia the way
a therapist would by supporting her, challenging her, and providing a framework (through
the card system) for her journey. As much as the story is about Amalia, it’s also about her
relationship with Ljos and how this facilitates her growth.
Playing with RPG Expectations
When crafting Amalia’s narrative, I leveraged the conventions of traditional video
game stories (especially role-playing games, or RPGs) to subvert the player’s expectations.
In games like Final Fantasy VII (Square, 1997) or Fire Emblem (Intelligent Systems,
1990-2023), the player takes on the role of a hero, traveling from town to town to slay
monsters or other enemies until they gain enough power to take on the final boss. For the
most part, progression is linear, dead enemies stay dead, losing simply creates a “Game
Over” where the game pretends that the loss never happens, until the hero defeats evil and
the world is saved. With Cards of Heart, we used some of the familiar elements of a
traditional RPG narrative to subvert the player’s expectations and show how a mental
health journey is different from the types of stories players are typically conditioned to
expect: the main character, Amalia, was not the hero, but a village friend that the hero left
behind; her confrontations weren’t about killing her enemies, but learning the skills to
manage them; losing didn’t pause time, but provided an opportunity for Amalia to recover
and move forward; and ultimately, Amalia’s journey wasn’t about beating her Shadows, but
learning how to understand and live with them.
28

A major part of this narrative subversion came in the form of “the recovery loop.” In a
typical RPG, losing a battle would result in a Game Over, a reload screen, and starting from
the last save point. In such cases, the game typically doesn’t acknowledge that the player
has lost at all. However, in mental health, losing and becoming overwhelmed is part of the
process; if the Shadows are strong and we get dealt a bad hand, we may not be able to
manage our circumstances on a given day. In contrast to the standard reload, I wanted the
game to acknowledge that failure and practice is perfectly normal. As a result, in Cards of
Heart, when Amalia loses a battle, she expresses that she’s become overwhelmed before
returning home and practicing self care before she feels confident enough to leave and
explore the town once again. Later in development, I took a lesson from the compelling loop
of Supergiant’s Hades (2020), where failure is an opportunity to upgrade the player’s
permanent abilities and advance the story, and actively made Amalia’s recovery a source of
strength, allowing her to upgrade one of her cards before re-attempting to face the
Shadow. In this way, previous failures are turned directly into a benefit, where upgraded
cards are a symbol of perseverance for players who keep playing despite losing.
An Unresolved Resolution
Because I wanted to design the game to have a lasting impact on the player, I had to
carefully consider the ending and what message the game would send to the player once
they put the game down. Having Amalia’s story wrap up in a neat ending seemed to be at
odds with the idea that mental health is an ongoing process, but without a sense of closure
it could be difficult for the player to feel like Amalia had actually made progress. To resolve
this tension, I created a frame narrative for the story, where the journey presented in the
game is actually present-day Amalia writing about her previous experiences. While this is
the story that she’s chosen to tell, she describes how the Shadows continued to return in
29

different forms. Finally, the game concludes with Amalia preparing to present her new story
to her mentor, which suggests the beginning of a new journey: Amalia sharing her story
with the world. By leaving the end of Amalia’s story ultimately unresolved, the player is
invited to think about how these cycles play out within their own lives even after they’ve
put the game down.
3.4 Cozy Fantasy: Serious Content with an Approachable
Aesthetic
Making Mental Health Approachable
Since the target audience of this game includes young adults who don’t necessarily
have a lot of experience talking about mental health, I wanted the concepts to be as
approachable as possible. One genre rapidly growing in popularity in the wake of the 2020
pandemic is “cozy games,” which are games that are typically seen as wholesome and
useful for destressing. While other genres are defined by the mechanics a player can expect
to see in the game, cozy games are “defined by the feelings the players associate with
them” (Carlos, 2024). While coziness is often associated with lighthearted gameplay, there
is also evidence that “dissonant” coziness, where “the cozy aesthetic creates a safe
environment for exploring a difficult theme,” can be an effective tool for inviting audiences
into experiences with otherwise uncomfortable subjects (Waszkiewicz & Bakun, 2020).
Games like Wylde Flowers and Stardew Valley demonstrate how a cozy atmosphere can be
conducive for giving players the time and space to address serious topics like grief and
validate players by recognizing the presence of loss and pain as a natural part of the human
experience (Howe & Cifre, 2024). When thinking about the world Amalia would inhabit, I
decided that Cards of Heart would be a cozy game, and that the game space would create
an appealing and safe environment for players to engage with the game’s serious topics
30

while also capturing the attention of players who would typically shy away from playing a
“mental health game.”
I also wanted Amalia’s world to have a little bit of magic in it. While I am admittedly a
fantasy nerd myself, fantasy can also be a way of providing a safe space for people to
address serious themes. When evaluating the computerized CBT program SPARX (2021),
participants enjoyed the game’s fantasy setting and preferred it to a realistic, modern
setting (Cheek et al., 2014). Magic could also be used as a metaphor to give difficult to
define mental health concepts a physical form: the Shadows themselves were a magical,
literal version of cognitive defusion, separating Amalia from her negative self-talk
(Cognitive Behavioral Therapy Los Angeles, 2022). When I presented this idea to my
external advisor, Dr. Raffael Boccamazzo, he was excited by the possibilities of using the
metaphor of light and darkness to describe cognitive distortions, saying [sic]: “Shadows are
a natural byproduct of light… they’re real but also illusory, depending on the angle you look
at [them]. They can be bigger or smaller, but there’s something real that casts the shadow…
you’re not trying to eliminate the kernel of truth, just trying to see past the shadow”
(personal communication, November 28, 2023). Rather than good versus evil, the magical
system in the game evokes the dichotomy of clarity versus vagueness, as Amalia’s cards of
light (formed from distinct, grounded thoughts and techniques) reduce the power of the
Shadows’ foggy, disruptive statements while also leaning into the classic trope of light
versus darkness familiar to fans of RPGs.
Considering Diversity and Inclusion
As part of making the game “approachable,” I also wanted to consider how people
from different backgrounds and identities would relate to the game. When discussing
mental health, it’s impossible to ignore the role of intersectional identities and the complex
31

effects of discrimination, structural inequalities, differences in protective factors, and more
on a person’s mental health and wellbeing (French et al., 2019; Fagrell Trygg et al., 2019).
The downside of having a distinct protagonist was that the game would largely be framed
through her experience as a cis, white, questioning woman. However, representation itself
can be an important form of inclusion that helps players feel acknowledged and engaged
(Shaw 2014). With this in mind, the team and I created a cast of characters in Respite with
different ages, body types, genders, sexual orientations, and race/ethnicities with their own
substories focused on their personal struggles and coping strategies. We hoped that by
including these stories, more players would see themselves reflected if not in Amalia, then
in the other characters of Respite and feel more connected to the game as a result.
32

Chapter 4: Production and Development
4.1 Recruitment and Managing the Team
I pitched this core idea to the faculty and student body at the end of the spring. At the
time, I wasn’t sure if anyone would want to work on a game about mental health, so I was
shocked when dozens of students expressed interest, with the desire to see more mental
health stories represented in video games as their number one reason for wanting to join
the project. By the summer, I had a team of 21: 3 UI/UX designers, a composer, a sound
designer, a level designer, 4 narrative designers, 3 systems designers, 5 artists, an engineer,
a producer, and myself, and in the fall that number would grow to a maximum team size of
38.
Initially, I was intimidated by the idea of managing a large team. However, I found
that Cards of Heart, as a game designed for impact, had an extra strength: we were all
aligned towards the same goal. It was never “my vision” versus “the team’s vision,” but all of
us working together to maximize the game’s impact. Because the team was made up of
college students who are part of the target audience, I encouraged my team members to
incorporate their thoughts and experiences into the project to represent a diverse set of
perspectives on therapy and mental health. To facilitate this codesign, I made sure that
everyone on the team had a baseline understanding of the concepts in the game by
creating a bank of resources that would be easily digestible even for team members with
little to no experience with psychology (Figure 14). Throughout the course of development,
these resources, as well as feedback from subject matter experts, created boundaries that
the team could exercise creative freedom within. In every meeting, we would evaluate our
design decisions by asking: how does this align with the messages we want to convey? And
how does this feel compared to our own experiences of mental health? While I was the
33

“team expert” on mental health due to my experience with psychology literature and
communication with subject matter experts, the team brought their personal experiences
to every elements the project, which deepened the game’s authenticity and appeal.
Figure 14. A list of mental health resources provided to the Cards of Heart team
through Discord.
4.2 Collaboration with Subject Matter Experts
Throughout the project, I was also fortunate enough to collaborate with several subject
matter experts, including Dr. Jeffery Newell and Dr. Elizabeth Kilmer. By asking them
questions and through playtests of my current prototypes, I was able to recalibrate
different elements of the project to be more in line with their opinions and experiences as
clinicians (especially working with students and young adults who play video games). I
34

would take careful notes during these conversations, so that I could relay the information
to my team members later or incorporate them into my designs.
I also had the distinct pleasure of working with Dr. Raffael Boccamazzo (Dr. B), from
the organization Take This as my external advisor. In our monthly meetings, Dr. B offered
numerous insights drawn from his experience as both a clinical psychologist and game
design consultant. When we began discussing the project, he was a huge proponent of
letting the mental health content be implicit and intuitive rather than explicit and didactic,
citing his own learnings from his Gardens of Fog D&D module and how he wished, in
retrospect, that he hadn’t made the mental health content so overt (Benham et al., 2019).
As my narrative team and I began to flesh out Amalia’s journey and struggles, Dr. B
suggested creating a case conceptualization diagram (Beck 2021) for Amalia based on
cognitive behavioral therapy (Figure 15). This truly was a genius move for our team:
creating a case conceptualization for Amalia allowed us to design her character from the
inside out, logically following how her early childhood experiences led to her core beliefs
and rules of living and how exactly her “mental health struggles” present themselves in the
way she thinks, acts, and feels. Doing this exercise allowed the narrative team to get to
know Amalia on a deeper level and helped us in leaps and bounds with character
consistency, and creating the Miro board allowed the team to have a dialogue with Dr. B
asynchronously, which led them to understand more about how we could create an
authentic and respectful depiction of mental health through Amalia. Doing this exercise
was one of my favorite parts of the entire narrative design process, and is a trick I will
certainly use in the future.
35

Figure 15. The case conceptualization for Amalia, taken from the narrative design
Miro. The structure is based on typical case conceptualizations seen in cognitive behavioral
therapy. The full Miro board can be found at
https://miro.com/app/board/uXjVMy4vOm8=/?share_link_id=356399620490.
36

4.3 Playtesting Methodology and Insights
In addition to playtesting with subject matter experts, we also tested with members of the
target audience: young adults who play video games from the School of Cinematic Arts. At
first, these playtests were weekly playtests of the paper prototype of the card system,
observing playtester feedback before asking a standardized set of interview questions, but
after we developed a digital prototype in the beginning of fall 2023 we switched to
internally playtesting new mechanics for the card system with the paper prototype and
having fresh playtesters play the digital version. While we made adjustments over the
course of the year, such as deepening the heuristics of the card battle system and
enhancing the nuance of Amalia’s therapeutic journey with input from subject matter
experts, the core game loop, system, and narrative remained relatively unchanged.
However, two main areas of focus for iteration emerged over the course of development: 1)
usability, and 2) scope. However, in addition to these more mechanical/developmental
insights, we also learned a lot about our intended impact, which will be discussed in the
next section.
Usability- Intuition versus Explanation
Because the game was so densely packed with gameplay information, story, and
impact content, one of the main challenges was striking the balance between ensuring the
player understood the mental health elements of the system and getting out of their way to
let them experience the game. While we tried not to be too didactic, our early versions
strayed too far in the opposite direction, with players not understanding where they were
supposed to go when exploring the overworld or having a hard time retaining the rules of
the card battle system without talking to the designer running the playtest. Through
multiple rounds of iteration, we created more clear visual guidance for the player to avoid
37

introducing walls of explanatory text, but even in our latest iterations a portion of players
still found the card battle confusing until they found their rhythm.
We learned very quickly that we needed to create a tutorial early in development.
After the first round robin of fall term, it was immediately clear that there was no way a
fresh playtester could understand the card system without a developer there to guide
them, and since we wanted to distribute the build to outside playtesters we would want a
tutorial in-engine as soon as possible. As a result, we pivoted from focusing on the
narrative climax of the game (the final battle) to the very beginning (the tutorial).
Ultimately, this made the build much stronger, giving us the time to test several iterations
of our tutorial to determine what amount of information we could give to the player at the
beginning of the game without overwhelming them.
Our overworld also had to undergo several rounds of iteration. In terms of impact
priorities in the game, the card battles were the focus of the mental health content, while
exploration was meant to help the player acquire cards that were drawn from meaningful
experiences in Amalia’s daily life. However, in early versions of the game players would
spend large amounts of time wandering the overworld looking for interaction points and
often even get lost, which killed the pace of the game and drew them away from the core
systems and engagement with the mental health themes. While we wanted a genuine
feeling of “drawing strength from everyday struggles,” we realized we needed to condense
the player’s possible interaction points and tell them more clearly where they had to go
next so that exploration off the beaten path was a choice rather than an accident. Once we
adjusted the layout and size of the overworld, players were able to find their way through
the experience much better and their overall enjoyment and understanding of the game
increased, which highlighted how important it was to consider where we wanted our
players to be spending their time.
38

Scope- Not the “30 Hour RPG”
As we started building the game, I realized that a full-blown RPG would be far too
large to create in one year. Within weeks of pitching my idea, I cut the idea of random
encounters, a traditional staple in RPGs, and over the course of development we cut other
large portions of the game, including a whole fourth Shadow location and memory. To
manage the disappointment of letting things go, my team members and I would joke that a
proposed idea belonged in the “30 hour RPG” version of the game, which helped us
acknowledge that although we would love to make a full RPG experience like we see in
commercial games, we had to temper our expectations. Setting this precedent early in
development helped the team stay on the same page in terms of the amount of content
that would make it into the game, giving us time to work on polish and details for the final
version.
39

Chapter 5: Impact
5.1 Overall Response to the Game and Relationship to Amalia
In our informal playtesting after the Winter Showcase, we asked players to rate their
enjoyment of our pre-alpha build (n =9). Across the board, on a scale of 1 to 5 players highly
rated different parts of the experience as “enjoyable,” including the card battles (4/5),
overworld exploration (3.2/5), music (4.1/5), graphics (4.6/5), and general gameplay (4.3/5).
Although these players were only able to engage with the beginning portions of the game,
we were excited that players enjoyed both halves of the experience and wanted to play
more, suggesting to us that the combination of card battles and role-playing resonated
with the audience.
Players also reported feeling connected to our main character, Amalia, with an
average score of 4.6/5. When we asked players why they identified/did not identify with
her, they said: “[I] totally related to her intrusive thoughts and thinking patterns. Her
journey feels inspiring!” “relatable self esteem issues,“ and “I felt like her struggles and the
methods she used to cope with her stressors were similar to my own.” Playtesters enjoyed
being able to see Amalia’s different expressions in dialogue and how she handled herself in
“quieter” moments, such as cleaning her room. The juxtaposition of Amalia’s adventure with
Ljos and her everyday tasks like cooking or cleaning helped her resonate as a character
with multiple dimensions.
5.2 Representation of Mental Health
We also asked playtesters if the game made them think of mental health challenges and
strategies, and if so, why. We were pleased to see that players rated this question well
above the midpoint, with an average score of 4.4/5. Players were surprised by how directly
40

the card battles related to their own lives, saying that the techniques in the game were
“exactly the kind of things that would help me if I wasn’t feeling good.” Conversely, students
with more mental health literacy expressed that “[the cards] and techniques were similar to
what I learnt in cognitive behavioral therapy.” Both types of players were excited to see
mental health represented authentically in a video game and expressed that playing the
game made them feel “empowered,” “motivated,” and “hopeful.”
As I dug into the data, I noticed that playtesters with different playstyles were citing
the elements that resonated with their personal tastes; for example, players who enjoyed
card games mentioned that the card mechanics made them reflect on their own mental
health, while RPG fans struggled with understanding the card system but resonated with
mental health messages in the story, characters, and world. This insight changed the way I
thought about the impact of the game, as I realized that by incorporating the messages
into different elements of the game, we were able to reach different types of players. Every
player didn’t have to get every message from every element, but as long as there was
enough of the mental health content in the parts of the game they were interested in, they
would take something away from the experience.
5.3 Formal Playtesting Process
In addition to informal playtesting, I’m also currently conducting a formal evaluation to
measure the entertainment efficacy of the game as part of my thesis. Alongside the
Creative Media and Behavioral Health Center, I designed a study that was submitted to the
USC Institutional Review Board (IRB) for approval of human subjects research and began
recruiting participants at the end of February. The study aims to measure the
entertainment efficacy of the game through quantitative and qualitative data on usability,
performance, how the game made the player feel, and whether it was a valuable
41

experience. While the data is still being collected, I hope to publish the results in a future
paper.
42

Chapter 6: Conclusion
As mental health becomes less stigmatized in our society, conversations about what we
struggle with are becoming increasingly acceptable in our social landscape. But in these
conversations, there’s often very little shared understanding between clinical terminology
and pop psychology trends that circulate on social media. Cards of Heart is an attempt to
bridge this gap for college students and young adults, utilizing the genre of cozy games to
create a new, interactive experience that allows players to explore mental health
challenges and ways to manage them in their daily lives. My hope is that players will come
away from the game feeling empowered to build resilience in the face of their own
struggles and more willing to engage in broader conversations about mental health.
In the future, I plan to continue collecting and analyzing the results of formal testing
to see whether the game is accomplishing its goals of being both fun and functional as a
tool for mental health literacy and awareness, and I hope to publish the results after I
graduate. I would also like to test the game with other populations that might benefit,
including teens (with the enhanced approval necessary for working with minors) as well as
clinicians who work with young adults, to see if a) they can understand the game, even if
they don’t have as much video game literacy as their clients, and b) the game could be a
resource they would be willing to use in their practice or recommend to their clients. I also
plan to continue distributing the game (for free) on online platforms like itch and Steam,
and we just released the game on the early access version of the platform KOZEE, which is
dedicated to cozy and mental health focused games. In addition to distributing the game
itself, I would also like to manage a small community forum on Reddit and social media;
since fostering conversation is a key part of the project, I want to create a safe online space
where those conversations can start to happen.
43

Ultimately, I hope that Cards of Heart can be used as a talking point, that players can
share the game with their friends as a way to express what they’re going through, or that a
clinician can recommend the game to one of their clients and reflect on the experience of
playing the game during their session. My dream is for Cards of Heart to become part of a
growing body of games committed to representation and advocacy around mental health,
helping players feel more compassionate, understanding, and empowered in broader
conversations around mental health and their own mental health journeys.
Finally, as a creator interested in designing games for mental health, I have learned
so much by working on Cards of Heart. Practically, I have three key takeaways: first, be
open to exploring different genres. If I hadn’t allowed myself to experiment with making a
card game out of a scientific paper, Cards of Heart wouldn’t exist at all. Second, literature
and theory can be useful, but be sure to incorporate insights from subject matter experts
and personal experiences to bring the game to life with authenticity and appeal. And third,
incorporate the mental messages at multiple levels to resonate with different play styles,
with an emphasis on concepts over jargon. While these are all learnings that I will take with
me into my future projects, more than anything, this experience has taught me that there
definitely is a place for games that help us connect with each other around mental health,
and I’m excited to continue creating and learning from games in this space in the years to
come.
44

Bibliography
AIM Cards. Anna Freud Centre. (n.d.). https://manuals.annafreud.org/ambit-aim/index.html
American College Health Association. (2024). American College Health
Association-National College Health Assessment III: Reference Group Executive
Summary Fall 2023.
Arango, C., Díaz-Caneja, C. M., McGorry, P. D., Rapoport, J., Sommer, I. E., Vorstman, J. A.,
McDaid, D., Marín, O., Serrano-Drozdowskyj, E., Freedman, R., & Carpenter, W. (2018).
Preventive Strategies for Mental Health. The Lancet Psychiatry, 5(7), 591–604.
https://doi.org/10.1016/s2215-0366(18)30057-9
Beck, A. T., & Bredemeier, K. (2016). A Unified Model of Depression: Integrating Clinical,
Cognitive, Biological, and Evolutionary Perspectives. Clinical Psychological Science,
4(4), 596–619. https://doi.org/10.1177/2167702616628523
Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). The Guilford
Press.
Benham, B., Boccamazzo, R., & Rose, H. (2019). Gardens of fog - a Take This adventure.
Dungeon Masters Guild.
https://www.dmsguild.com/product/279037/Gardens-of-Fog
Birk, M. V., & Mandryk, R. L. (2016). The benefits of digital games for the assessment and
treatment of mental health. In CHI 2016 Workshop Computing in Mental Health.
Brady, M. (2022). The Use of Commercial Video Games for Mental Health: The State of the
Literature [Unpublished manuscript]. School of Cinematic Arts, University of
Southern California, Los Angeles, United States.
Carlos, K. D. (2024, February 15). Cozy Gaming in a chaotic world: How “vibes” defined a
genre. Sooner Esports.
https://www.sooneresports.org/2024/02/16/cozy-gaming-in-a-chaotic-world-how
-vibes-defined-a-genre/
Celeste [Steam]. (2018). Maddy Makes Games.
Cheek, C., Bridgman, H., Fleming, T., Cummings, E., Ellis, L., Lucassen, M. F., Shepherd, M., &
Skinner, T. (2014). Views of young people in rural Australia on Sparx, a fantasy world
developed for New Zealand youth with depression. JMIR Serious Games, 2(1).
https://doi.org/10.2196/games.3183
45

Cognitive Behavioral Therapy Los Angeles. (2022). Cognitive Defusion Techniques and
Exercises. Cognitive Behavioral Therapy Los Angeles.
https://cogbtherapy.com/cbt-blog/cognitive-defusion-techniques-and-exercises
Coleman, D., Black, N., Ng, J., & Blumenthal, E. (2019). Kognito’s avatar‐based suicide
prevention training for college students: Results of a randomized controlled trial and
a naturalistic evaluation. Suicide and Life-Threatening Behavior, 49(6), 1735–1745.
https://doi.org/10.1111/sltb.12550
Critcher, C. R., Dunning, D., & Armor, D. A. (2010). When Self-Affirmations Reduce
Defensiveness: Timing is key. Personality and Social Psychology Bulletin, 36(7),
947–959. https://doi.org/10.1177/0146167210369557
Dindo, L., Van Liew, J. R., & Arch, J. J. (2017). Acceptance and commitment therapy: A
transdiagnostic behavioral intervention for mental health and medical conditions.
Neurotherapeutics, 14(3), 546–553. https://doi.org/10.1007/s13311-017-0521-3
Elias, G. S., Garfield, R., Gutschera, K. R., Zimmerman, E., & Whitley, P. (2020). Characteristics
of Games. The MIT Press.
Fagrell Trygg, N., Gustafsson, P. E., & Månsdotter, A. (2019). Languishing in the crossroad? A
scoping review of intersectional inequalities in Mental Health. International Journal
for Equity in Health, 18(1). https://doi.org/10.1186/s12939-019-1012-4
Fincham, G. W., Strauss, C., Montero-Marin, J., & Cavanagh, K. (2023). Effect of breathwork
on stress and mental health: A meta-analysis of randomised-controlled trials.
Scientific Reports, 13(1). https://doi.org/10.1038/s41598-022-27247-y
Fire Emblem Series [Nintendo Platforms]. (1990-2023). Intelligent Systems and Nintendo.
Fleming, T., Lucassen, M., Stasiak, K., Sutcliffe, K., & Merry, S. (2021). Technology matters:
SPARX – computerised cognitive behavioural therapy for adolescent depression in a
game format. Child and Adolescent Mental Health, 26(1), 92–94.
https://doi.org/10.1111/camh.12444
Fleming, T. M., Stasiak, K., Moselen, E., Hermansson-Webb, E., Shepherd, M., Lucassen, M.,
Bavin, L. M., & Merry, S. N. (2019). Revising computerized therapy for wider appeal
among adolescents: Youth Perspectives on a revised version of Sparx. Frontiers in
Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00802
French, B. H., Lewis, J. A., Mosley, D. V., Adames, H. Y., Chavez-Dueñas, N. Y., Chen, G. A., &
Neville, H. A. (2019). Toward a psychological framework of radical healing in
communities of color. The Counseling Psychologist, 48(1), 14–46.
https://doi.org/10.1177/0011000019843506
46

Fullerton, T. (2019). Game Design Workshop: A playcentric approach to creating innovative
games. CRC Press, Taylor & Francis Group.
Garrido, S., Millington, C., Cheers, D., Boydell, K., Schubert, E., Meade, T., & Nguyen, Q. V.
(2019). What works and what doesn’t work? A systematic review of digital mental
health interventions for depression and anxiety in young people. Frontiers in
Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00759
Gillihan, S. (2019). The CBT deck for clients and therapists: 101 practices to improve
thoughts, be in the moment, and take action in your life. PESI Publishing.
Grajfoner, D., Harte, E., Potter, L., & McGuigan, N. (2017). The effect of dog-assisted
intervention on student well-being, mood, and anxiety. International Journal of
Environmental Research and Public Health, 14(5), 483.
https://doi.org/10.3390/ijerph14050483
Grinspoon, P. (2022, May 4). How to recognize and Tame your cognitive distortions. Harvard
Health.
https://www.health.harvard.edu/blog/how-to-recognize-and-tame-your-cognitivedistortions-202205042738
Gulliver, A., Griffiths, K. M., & Christensen, H. (2010). Perceived barriers and facilitators to
mental health help-seeking in young people: A systematic review. BMC Psychiatry,
10(1). https://doi.org/10.1186/1471-244x-10-113.
Hades [Steam]. (2020). Supergiant Games.
Howe, C., & Cifre, D. (2024, March). The Cozy Craze: Secrets Behind Beautiful, Safe, Ritual
Experiences. Game Developers Conference. San Francisco; California. Retrieved
April 22, 2024, from https://gdcvault.com/
Hu, C. (2021). Hedge Hug [itch]. https://clairehu.itch.io/hedge-hug.
Iwasaki, Y. (2001). Contributions of leisure to coping with daily hassles in university
students’ lives. Canadian Journal of Behavioural Science / Revue Canadienne Des
Sciences Du Comportement, 33(2), 128–141. https://doi.org/10.1037/h0087135
Jemmali, C., Bunian, S., Mambretti, A., & El-Nasr, M. S. (2018). Educational game design: an
empirical study of the effects of narrative. FDG ’18: Proceedings of the 13th
International Conference on the Foundations of Digital Games, 1–10.
https://doi.org/10.1145/3235765.3235783
Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollitt, P. (1997b).
“Mental health literacy”: A survey of the public’s ability to recognise mental
disorders and their beliefs about the effectiveness of treatment. Medical Journal of
Australia, 166(4), 182–186. https://doi.org/10.5694/j.1326-5377.1997.tb140071.x.
47

Kutcher, S., Wei, Y., & Coniglio, C. (2016). Mental health literacy. The Canadian Journal of
Psychiatry, 61(3), 154–158. https://doi.org/10.1177/0706743715616609.
Levitt, H. M., Rattanasampan, W., Chaidaroon, S. S., Stanley, C., & Robinson, T. (2009). The
process of personal change through reading fictional narratives: Implications for
psychotherapy practice and theory. The Humanistic Psychologist, 37(4), 326–352.
https://doi.org/10.1080/08873260903113501
Linehan, M. M. (2015). DBT skills training manual (2nd ed.). The Guilford Press.
Liverpool, S., Mota, C. P., Sales, C. M., Čuš, A., Carletto, S., Hancheva, C., Sousa, S., Cerón, S.
C., Moreno-Peral, P., Pietrabissa, G., Moltrecht, B., Ulberg, R., Ferreira, N., &
Edbrooke-Childs, J. (2020). Engaging children and young people in Digital Mental
Health Interventions: Systematic review of modes of delivery, facilitators, and
barriers. Journal of Medical Internet Research, 22(6). https://doi.org/10.2196/16317
Ma, Y., & Siu, A. F. (2020). Dispositional Mindfulness and mental health in hong kong college
students: The mediating roles of decentering and self‐acceptance. Australian
Journal of Psychology, 72(2), 156–164. https://doi.org/10.1111/ajpy.12269
McCandless, S. & Johnston, S. (n.d.). Dialectical Behavior Therapy: A Visual Review
[PowerPoint slides]. South Central MIRECC.
https://www.mirecc.va.gov/visn16/docs/DBT_Visual_Review_Flash_Cards.pdf
McColl, C. (2021, August 19). A retelling of anxiety through the thoughtful platformer
Celeste. Byteside.
https://www.byteside.com/2021/08/a-retelling-of-anxiety-through-celeste-mental
-health-platform-game/
Meng, L. (2022). Blossom [Physical Installation].
Morton, D. P., Hinze, J., Craig, B., Herman, W., Kent, L., Beamish, P., Renfrew, M., & Przybylko,
G. (2017). A multimodal intervention for improving the mental health and emotional
well-being of college students. American Journal of Lifestyle Medicine, 14(2),
216–224. https://doi.org/10.1177/1559827617733941
National Institute of Mental Health. (2022, August 8). Emotional wellness toolkit. U.S.
Department of Health and Human Services, National Institutes of Health. Retrieved
April 21, 2024, from
https://www.nih.gov/health-information/emotional-wellness-toolkit
National Institute of Mental Health. (2023). Mental illness. U.S.
Department of Health and Human Services, National Institutes of Health. Retrieved
April 21, 2024, from https://www.nimh.nih.gov/health/statistics/mental-illness
48

Nimrod, G., Kleiber, D. A., & Berdychevsky, L. (2012). Leisure in coping with depression.
Journal of Leisure Research, 44(4), 419–449.
https://doi.org/10.1080/00222216.2012.11950272
Nitschke, J. P., Forbes, P. A., Ali, N., Cutler, J., Apps, M. A., Lockwood, P. L., & Lamm, C.
(2020). Resilience during uncertainty? greater social connectedness during
COVID‐19 Lockdown is associated with reduced distress and fatigue. British Journal
of Health Psychology, 26(2), 553–569. https://doi.org/10.1111/bjhp.12485
Nomada Studio (2018). Gris [Steam]. Devolver Digital.
Pokémon Series [Nintendo Platforms]. (1996-2022). Nintendo.
Reynolds, E. (2012). Nevermind: Creating an Entertaining Biofeedback-Enhanced Game
Experience to Train Users in Stress Management (thesis). ProQuest LLC, Ann Arbor.
Retrieved March 13, 2024, from
https://www.proquest.com/pqdtlocal1006272/docview/1026566262/517EF9383392
429APQ/2?accountid=14749&sourcetype=Dissertations%20&%20Theses.
Shaw, A. (2014). Representation matters (?): When, how and if representation matters to
marginalized game audiences. In L.A. Lievrouw (Ed.), Challenging communication
research (pp. 105-120). Peter Lang. https://doi.org/10.3726/978-1-4539-1273-7
Sherman, D. K., Lokhande, M., Müller, T., & Cohen, G. L. (2021). Self‑affirmation interventions.
In G. M. Walton & A. J. Crum (Eds.), Handbook of wise interventions: How social
psychology can help people change (pp. 63–99). The Guilford Press.
Signs of the Sojourner [Steam]. (2020). Echodog Games.
Smyth, J. M., Johnson, J. A., Auer, B. J., Lehman, E., Talamo, G., & Sciamanna, C. N. (2018).
Online positive affect journaling in the improvement of mental distress and
well-being in general medical patients with elevated anxiety symptoms: A
preliminary randomized controlled trial. JMIR Mental Health, 5(4).
https://doi.org/10.2196/11290
Square (1997). Final Fantasy VII [PlayStation]. PlayStation.
Trama, A. (2021, April 5). Gris’ approach to modern psychological and social issues. Game
Rant.
https://gamerant.com/gris-approach-to-modern-psychological-and-social-issues/
?fbclid=IwAR2WWwtdbfIMbMv4O_hOqtl0zKeay9xcKN3x9dTY7bMWkDMuvJ9VHXuh
wiE
Voracious Games (2022). Potionomics [Steam]. Xseed Games.
49

Waugh, C. E., & Sali, A. W. (2023). Resilience as the ability to maintain well-being: An
allostatic active inference model. Journal of Intelligence, 11(8), 158.
https://doi.org/10.3390/jintelligence11080158
Waszkiewicz, A., & Bakun, M. (2020). Towards the aesthetics of Cozy Video Games. Journal
of Gaming & Virtual Worlds, 12(3), 225–240. https://doi.org/10.1386/jgvw_00017_1
Webb, C. A., Rosso, I. M., & Rauch, S. L. (2017). Internet-based cognitive-behavioral therapy
for depression: Current progress and future directions. Harvard Review of
Psychiatry, 25(3), 114–122. https://doi.org/10.1097/hrp.0000000000000139
Worsley, J. D., Pennington, A., & Corcoran, R. (2022). Supporting mental health and
wellbeing of university and college students: A systematic review of Review-level
evidence of interventions. PLOS ONE, 17(7).
https://doi.org/10.1371/journal.pone.0266725
50

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Val’s pelvic health journey: the educational power of storytelling

PDF

Exploring space literally & figuratively in Eight Moons to Eternity

PDF

Shepherds - cooperating from divergent path: a design exploration

PDF

Penrose Station: an exploration of presence, immersion, player identity, and the unsilent protagonist

PDF

That's not how it happened: unreliable narration through interactivity

PDF

Last broadcast: making meaning out of the mundane

PDF

Free Will: a video game

PDF

Oopz-Oofs: the creation of a dog simulator game

PDF

Egregore: de-mystifying the adventure game

PDF

Installation wizard: how communication makes or breaks a game

PDF

The Darkest Plague: insights on the development of an action adventure game

PDF

A game called Paako: the challenge of an autobiographical video game

PDF

The extension of our reality

PDF

Mechanics as metaphor: representing physical disability and aging in video game mechanics

PDF

Earth and ash: inventing (not reinventing) within interactive spaces

PDF

The Cleaner: recreating censorship in video games

PDF

The future of games and health: towards responsible interaction design

PDF

Hearth and home: interior design as tool and weapon in creating an atmosphere of dread

PDF

Jizo No Akumu: A psychological horror game exploration of generational trauma and mixed-race identity

PDF

The Glitch Witch

Asset Metadata

Creator Brady, Marielle J. (author)

Core Title Cards of Heart: a cozy role-playing card game for promoting mental health

School School of Cinematic Arts

Degree Master of Fine Arts

Degree Program Interactive Media (Games and Health)

Degree Conferral Date 2024-05

Publication Date 05/17/2024

Defense Date 05/15/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag Card games,cognitive distortions,cozy games,digital games,games for impact,mental health,OAI-PMH Harvest,Psychology,role-playing games,serious games,video games

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Nealen, Andy (committee chair), Bilson, Danny (committee member), Gotsis, Marientina (committee member), Huntley, Jim (committee member), Roberts, Sam (committee member)

Creator Email marielle@usc.edu,mariellebrady@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113939743

Unique identifier UC113939743

Identifier etd-BradyMarie-12918.pdf (filename)

Legacy Identifier etd-BradyMarie-12918

Document Type Thesis

Format theses (aat)

Rights Brady, Marielle J.

Internet Media Type application/pdf

Type texts

Source 20240517-usctheses-batch-1151 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu