Mental Illness In Video Games

Ian Mahar posted an excellent article over on Kotaku recently detailing the  portrayal of the mentally ill in video games. The article raises many important points that are equally applicable to storyline, game mechanics and NPC’s in MMO’s. What follows is the article in full:

Nobody Wins When Horror Games Stigmatize 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 stigmatizing 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% 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% of those surveyed said they would discuss a family member’s cancer diagnosis, compared to 50% for mental illness. When considering only those very likely to disclose, the percentages change to 48% and 25%, respectively.
  • Some of the strangest data relate to willingness to interact with someone that has a mental illness. 42% of respondents did not think it likely that they would socialize 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% 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% of the population is ostensibly unwilling to socialize with anyone with a psychiatric disorder, exactly who are they surrounding themselves with, given that ~3545% 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.

Nobody Wins When Horror Games Stigmatize Mental Illness

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 lobotomization.

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 institutionalized (and ostensibly, in the game’s story, subjected to clandestine experimentation), as opposed to individuals who are dangerous merely because of their insanity or institutionalization, which is an important and appreciated distinction.

The “dangerous asylum” trope is somewhat less insidious than the “crazed killer” trope, as it usually stigmatizes 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 stigmatization 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.

Nobody Wins When Horror Games Stigmatize Mental Illness

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 stigmatizing 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.

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

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One response to “Mental Illness In Video Games

  1. Interesting thoughts, Ian. Certainly this is a topic that is routinely given far less consideration than it ought to be in many forms of fiction – there is still an unquestioned assumption in videogames as well as other media such as films that (an often generalised, non-specific and unrealistic) ‘insanity’ explains violence, egocentrism and domination of others on the part of a particular character, in a way that would by no means be seen as acceptable by consumers of the same media if a character’s violence was explained by way of their being Black, for instance.

    This is obviously a broader issue, but one that’s particularly complex when it comes to horror since there is certainly a legitimate horror involved in the notion of losing touch with reality in some sense or losing the ability to mentally and emotionally function in the way that we are used to – it’s a common trope one way or another in The Twilight Zone and the work of many of the contributors to that show such as Richard Matheson or Harlan Ellison. It’s also a recurring topic in the work of HP Lovecraft and those he inspired. Obviously this is all with good reason to a point, although one must be careful that the topic is not handled in a way that perpetuates misconceptions and prejudices about the medical notion of mental illness, etc.

    On which note, I wanted to pick up on something that you mentioned in this article. You note that:
    “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.”

    You’re fairly even-handed here but I wanted to push a little bit further in terms of contextualising this. The game you mention is based on HP Lovecraft’s ‘Cthulhu mythos’ stories. Throughout the years there have been many different games (card games, roleplaying games, videogames, boardgames) inspired by Lovecraft – I can name about 10 off the top of my head – and the notion of ‘sanity’ has been a recurring concept which is often mechanically implemented, ever since the original ‘Call of Cthulhu’ roleplaying game.

    I think it’s arguable that ‘sanity’ is a complete misnomer for this concept, however, and that it actually has little or nothing to do with mental health in at least some applications of the idea. The core of ‘sanity’ in the Lovecraftian sense is not mental health in a medical sense, but rather a certain way of seeing the cosmos and one’s place within it. ‘Sanity’ erosion often means not succumbing to any identifiable mental illness, but rather losing touch with notions of purpose, humanity, meaning, etc in a way that isn’t easy to explain.

    This, however, goes some way to telling us why losing ‘sanity’ leads to suicide in the Call of Cthulhu videogame you mention – to lose ‘sanity’ is to lose a sense of one’s place in the world, to lose any notion of purpose in one’s life, to become aware of the utter indifference and absurdity of the cosmos, and the frail and vulnerable position occupied by humanity even as a species, let alone as individuals, in a way that makes life seem not only not *worth* living, but best escaped from – monstrous, cruel, incomprehensible and unbearable.

    Unfortunately this has always been somewhat confused both by game designers and game players with the everyday notion of ‘insanity’, to the detriment of the games in question. The roleplaying game Trail of Cthulhu explicitly disentangled these concepts by introducing ‘stability’ alongside ‘sanity’ – ‘stability’ is the mundane sense of mental health, whereas ‘sanity’ is the level of ignorance one is capable of maintaining of the horrific nature of reality (of which no human being – according to Lovecraftian lore – can bear the full extent).

    I think this is one of the great virtues of Trail of Cthulhu, in that it explicitly addresses and resolves this traditional confusion of mundane insanity and cosmic horror ‘insanity’, which are not to be confused if one is to achieve a valuable depiction of mental health and avoid furthering prejudice and stigma, etc. Certainly the concept could do with a much better name than ‘sanity’ (the Vampire roleplaying game has traditionally used a similar concept called ‘humanity’, which might be an interesting label to consider for this. Incidentally, ‘stability’ isn’t the best name in the world either, but that’s not the major concern here), but I think that the mechanical distinction at least resolves some of the problematic implications and misconceptions of Lovecraftian lore in relation to insanity/’insanity’ (and specifically their mechanical treatment within games). It allows us to distinguish a concept which serves an important narrative and mood function within this genre of horror from a concept which affects real people in the world in which we live, and which we must be careful in how we represent for the sake of said people.

    Perhaps this kind of distinction should be carefully used by those who wish to use the insanity trope in other horror contexts, as an aid to avoiding some of the crude and harmful uses of insanity as an object of horror. Of course there’s also the distinction between insanity itself as a state we are afraid of experiencing versus insane people as persons we are afraid of encountering, which is perhaps partially linked to this.

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