In Real Life

Nobody Wins When Horror Games Stigmatise Mental Illness

Public attitudes regarding mental illness are frequently apocryphal and damaging, and a major source of these views is media portrayal of a topic that affects all of us to some extent. A few months ago, an open letter was posted in response to a Kotaku article on the upcoming horror game, Outlast, which takes place in an asylum and includes violent criminal inpatients as enemies.

The letter, referring primarily to potentially stigmatising language used in a video from the article, was respectful, succinct and absolutely dead-on regarding a critical issue that we don’t discuss enough: portrayal of mental illness in media, including video games.

The goal of widely accessible media including movies, television, and video games isn’t necessarily (or even commonly) to correct unfounded views or social injustice. However, there is a social obligation to protect vulnerable members of society from misrepresentation, and to correct misrepresentations, especially within an industry partly responsible for disseminating them.

What’s the Big Deal?

In 2008, the Canadian Medical Association conducted an in-depth survey investigating the attitudes of Canadians regarding mental illness. Their results were as disheartening as they were surprising.

Here are some highlights:

  • 25-27 per cent of respondents would feel fearful or uneasy around someone with a mental illness.
  • Shame or stigmatic pressure regarding familial mental illness prevents family members of patients from discussing these issues with peers: 72 per cent of those surveyed said they would discuss a family member’s cancer diagnosis, compared to 50 per cent for mental illness. When considering only those very likely to disclose, the percentages change to 48 per cent and 25 per cent, respectively.
  • Some of the strangest data relate to willingness to interact with someone that has a mental illness. 42 per cent of respondents did not think it likely that they would socialise with a friend who had a mental illness. Not a serious mental illness; any mental illness. This jumps to more than half for work colleagues, and only 31 per cent would be willing to hire a landscaper with any mental illness.

Views in the US are likely similar or even worse, by the way.

What’s most surprising about these results is that, given the prevalence of mental illness, almost all of us at one time in our lives encounter it, either personally or through a friend, romantic partner, colleague, or other person close to us.

Given the prevalence of mental illness, almost all of us at one time in our lives encounter it…

If 40-50 per cent of the population is ostensibly unwilling to socialise with anyone with a psychiatric disorder, exactly who are they surrounding themselves with, given that ~35-45 per cent of the population will experience a mental illness at some point in their lives? And how much pressure does this put on individuals struggling with mental illness, in that they not only have to face their psychiatrically-related obstacles but also hide them, lest they be shunned by a shockingly large and callous proportion if the population?

What does this have to do with video games?
Popular media drive popular beliefs, which lead to reinforcement, adaptation, or abandonment of stigmatic views. So, are representations of mental illness in video games helping or hurting? Let’s look at some of the ways in which games address the issue of mental illness.

Storyline “Insanity”

A character’s mental illness is most commonly thrown into a story in order to tie up some loose exposition or backstory, or to try and justify a character’s behaviour. It’s usually the villain, and typically used to justify extreme violence or antipathy; in fact, a character’s insanity is rarely brought up outside of a violence-justifying context, with a few notable exceptions such as Heavy Rain and its portrayal of a mentally ill playable character, although the success of its efforts was mixed. The most common story devices are the “crazed killer” trope and the “horrific insane asylum trope.”

“Insane” murderous antagonists or villains are particularly common in video games, and this common misconception is worth noting as 1) sufferers of mental illness are not more violent than those unafflicted, and 2) they are actually twelve times more likely to be victims of violent crimes. It’s a trope that’s almost too common to require examples; however, one in particular was extreme enough to garner a public outcry.

The National Alliance on Mental Illness (NAMI) publicly denounced the game Manhunt 2, in which the protagonist initially escapes an insane asylum while fighting off murderous fellow patients, for “its irresponsible, stereotyped portrayal of mental illness,” and requested that the game be edited or recalled due to content that “unfortunately perpetuates and reinforces cruel, inaccurate perceptions that people who live with mental illness are violent.”

Besides Manhunt 2, other games have used an asylum as a dangerous setting of violent enemies (typically patients); obvious examples are Arkham Asylum and the upcoming Asylum.

It’s partly understandable why the asylum is a common location in horror games in particular. In past eras, psychiatric care was less refined and involved widespread misconceptions regarding causes and treatments of psychiatric disorders. These misconceptions led to treatments that would now seem abhorrent, such as lobotomisation.

In addition, early (and occasionally covert) research into the psyche was less hindered by ethical constraints, further contributing to the eeriness surrounding previous-era psychiatric interventions. For example, the CIA MKUltra “mind-control” experiments originating in 1950’s Montreal appear to play a narrative (or at least narrative-inspiring) role in the aforementioned Outlast (developed, appropriately enough, by Montreal-based Red Barrels).


It’s usually the villain, and typically used to justify extreme violence or antipathy


The article on Outlast that I mentioned initially was updated to point out that the game focuses on criminals who have been institutionalised (and ostensibly, in the game’s story, subjected to clandestine experimentation), as opposed to individuals who are dangerous merely because of their insanity or institutionalisation, which is an important and appreciated distinction.

The “dangerous asylum” trope is somewhat less insidious than the “crazed killer” trope, as it usually stigmatises to a lesser extent “violent” tendencies of patients and more the conditions of psychiatric institutions themselves. However, even this depiction can be detrimental, as it can make patients less likely to seek necessary institutional care and increases stigmatisation against psychiatric hospital inpatients if the presentation of the setting is unfairly done.

“Insanity” as a Game Mechanic

A more recent trend is the use of the player character’s (in)sanity within the actual game mechanics. There are a few prominent examples of this:

  • Amnesia: Dark Descent, in which the player’s sanity decreases in response to darkness, monsters, and disturbing events, causing hallucinations. However, in terms of inaccurate depictions of insanity leading to public misconception, this mechanic is fairly benign.
  • Similarly, in Call of Chthulu: Dark Corners of the Earth, the protagonist’s sanity decreases in response to disturbing game events, causing hallucinations and eventually (and bizarrely) the player character’s suicide. Apart from the implication that suicide is caused merely by witnessing disturbing events as opposed to underlying neurobiology, this mechanic is again less problematic than the more prevalent “crazy=violent” trope.
  • The Sims 3’s “Insane” trait is arguably a bit more problematic. “Insane” Sims wear bizarre clothes, make other Sims uncomfortable, talk about conspiracies (and also to themselves), are socially rude, rummage through trash cans, act like animals, and generally act as either a nuisance or joke. Obviously it’s intended as a bit of cartoonish fun, but comes off as an insulting depiction that perpetuates outdated and unfairly negative stereotypes of mental illness.

Positive Portrayals

There are a few games that try to portray mental illness in an accurate and awareness-raising manner, and as such deserve some attention.

In particular, Depression Quest, in which the player helps their character navigate his depression and its consequences, aims to combat stigma by “show[ing] other sufferers of depression that they are not alone in their feelings, and to illustrate to people who may not understand the illness the depths of what it can do to people,” according to the game’s website. It attempts to faithfully explore what a depressed patient might experience, and part of the game’s proceeds go to a charity combating depression and its stigma; as such, the game was garnered wide-ranging praise from depressed individuals and gaming experts alike.

Contrast this with its antithesis, Billy Suicide, which more flippantly deals with depression and suicide in an arguably detrimental manner, and in which your character alternately jerks off, drinks, strips on camera, and watches TV in order to stave off killing himself (and to get laid) for another day. Admittedly, it’s really an online flash game as opposed to a major-label release, but given its subject matter and the attention it has received it merits mentioning. Billy Suicide’s overall impact is negative according to multiple mental health advocacy groups who (justifiably) have publicly denounced the game, claiming that it’s a “light-hearted” and “irresponsible” take on an incredibly serious topic.

Why Should We Care?

Obviously the intent and purpose of video games (with the exception of games like Depression Quest) is not to enlighten the user on societally relevant issues. The content of a game, as with any other media, is a reflection of the message (and experience) that its creator desired to express to its consumers, and content creators should be free to explore whatever views they wish, regardless of potential controversy.

I’m not arguing that we should necessarily censor negative messages or force content creators to insert positive societally-beneficial content into their creations, nor that games need to include dry, boring gameplay mechanics or characters that realistically explore the depths of human suffering.

However, given the broad audience and potential for influence of such a large industry, there is an onus to consider the impact of a game’s content on society as a whole. Rockstar hasn’t necessarily acted immorally by reinforcing negative stereotypes of the mentally ill with Manhunt 2, but their critics have the right to question whether this stigmatising message is necessary to convey whatever intent the designers had in including it. Similarly, content that addresses the complex and nuanced issues regarding mental illness and stigma, such as Depression Quest, should be lauded as providing something beneficial, in that users gain insight and understanding with stigma reduction as a consequence.

As with other societally relevant issues, mental illness affects a large proportion of the population directly and a vast majority of the population indirectly, and views regarding it have real and serious consequences on the suffering and health of the people involved. Although reducing stigma shouldn’t be a fixed obligation for video games, we have a moral obligation to reduce suffering and increase well-being in vulnerable members of society, and (regardless of the type of media) content creators and audiences alike should keep this obligation in mind.

Top picture: Shutterstock

If mental illness is affecting you or someone you know, call Lifeline on 13 11 14.


Ian Mahar is a neuroscience PhD candidate researching mental illness at McGill University.


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