One of the most destructive aspects of mental illness is that it is invisible. There is no obvious physical indication that someone is struggling with a mental health concern.

They don’t swell up or wear a cast or waste away, evoking the sympathy and understanding of those around them. They sit at their cubicles or their home office desks or behind their bathroom mirrors and often suffer in silence.

The discussion surrounding mental health can also be invisible. It’s one of the least-understood public health concerns, despite how common mental health problems can be in the population. This lack of open conversation creates an atmosphere in which mental health issues and the people who live with them are stigmatized and made to feel like outsiders, unable to address their concerns with family, friends and coworkers for fear of being ostracized or misunderstood.

Where video games fit in

Representation is the key to kickstarting discussion, and video games have taken a woefully one-dimensional approach in the mental health conversation. While there’s no shortage of mental health-related content in today’s games, it falls into one of two specific camps, neither of which confront the complex and nuanced issues with the empathy and consideration they deserve.

If you encounter a game that deals with issues of mental health, chances are it’s a horror game. The genre loves to play around with mental illness; specifically the vague, generalized Saturday Morning Cartoon-style "insanity" that doesn’t match any real definition of the term. In fact, the concept of sanity is so ubiquitous within the genre as a thematic, narrative and mechanical device that several horror games feature [in]famous "sanity meters;" literally a way to quantify how "crazy" characters are.

These representations are as harmful as they are common. When discussing a topic as sensitive and misunderstood as mental illness, empathy and understanding are crucial, and this content fosters neither.

Developers perpetuate the societal disparity that breeds harmful stigma when they resort to generic, undefined, almost pseudo-mystical "insanity." It’s a brush-off and a hand-wave, painting mental illness as a magical black box we can neither see into nor ever hope to understand, rather than as a condition that real human people with brains and feelings and mortgages live with on a daily basis. There are few things that more clearly draw an "us and them" line in the sand.

Not only does this type of portrayal discourage the public at large from seeking further understanding, it also reinforces the idea that those who suffer from mental illness are broken, defective or otherwise "different." Sanity meters make appearances in horror games from Eternal Darkness: Sanity’s Requiem to Amnesia: The Dark Descent all the way down to the small indie genre entries like Knock-Knock.

These characters are dehumanized

These meters affect the player’s perception and experience of the in-game reality in some way. Typically as player characters become more and more "insane," and this is almost universally synonymous with scared or stressed, the world around them warps and changes. Monsters may appear, the corridors distort, sometimes precocious developers even give the insanity a meta-expression, such as Eternal Darkness’s seemingly "broken" game elements and increasingly glitchy graphics.

While this is a useful way to convey the very real impact that mental illness can have on those who live with it, it does so by suggesting that mental illness sufferers are somehow damaged; that their perception is untrustworthy and not representative of what things are "really" like, that their experience of reality is somehow less valid than that of "sane" people.

These characters are dehumanized, portrayed as mental disorders embodied and wrapped in ostensibly human packaging. Neuroatypicalilty cannot possibly be reconciled as just one of an infinite number of characteristics that comprise a holistically constructed person. It’s instead seen as a one-dimensional monolith, and just like the counterpart in Kubrick’s 2001, it renders those affected inane and irrational.

Insanity as motivation

The other primary representation mental health issues receive in games is equally unfavorable, and attaches not to the protagonists, but to the villains. Just as insanity has served as a McGuffin to underpin game mechanics and monster attacks in horror games, it has served as a main, and often sole, motivation for villains in action games.

The Silent Hill series, for example, famously uses monsters to symbolize the insecurities, shames or fears held by the characters. While the model was effective back in the days following the release of Silent Hill 2, it still represents an outside-looking-in approach to mental illness. These characters aren't aware of or in charge of their circumstances, they're made to run a horror gauntlet so that we can psychoanalyze them.

We’ve seen this for decades, and it’s stale. We want to empathize with our characters and feel like we’re helping them work toward a common goal. Steering a hapless victim around a haunted house gets boring, while taking an avatar on a journey of self exploration and reclamation paints a compelling picture of a type of power fantasy that is unconventional but still very relatable.

Recent games have begun to explore this angle. Knock-Knock, from developer Icepick Lodge, features a protagonist who spends much of the game rationalizing his hallucinations as an effect of his diminished emotional and mental state. The game’s dialogue — or rather, monologue — consists of the protagonist telling himself over and over that if he can just get to morning and the safety of daylight, his manifestations will give way to the calming rationality of the light.

The Cat Lady from Harvester Games removes yet another layer of metaphor. Susan Ashworth, the game's protagonist, begins the game as a suicide survivor who must come face-to-face with her mortality. Her quest is not one of survival — Susan is granted immortality at the game’s beginning so she can’t die — but of rebuilding.

Her quest takes place in the real world, not the prison of her mind. Rather than succumbing to the horrors of her own psyche, she is rediscovering the value of life through the process of making her world a better place, and helping others like her work through and survive traumatic ordeals.



This opens new narrative avenues for developers to explore. There are only so many bogeymen we can hide under beds and in closets to jump out and scare unsuspecting players before we’re retreading old ground. The real challenge — the part that gives writers creative freedom and unshackles them from worn-out genre tropes — is to confront and explore the reality of mental illness, and highlight the effective paths that conversation can take.

This opens new narrative avenues for developers to explore

UbiSoft’s Far Cry 3, no stranger to controversy, is a notable example of a game that stumbles over this particular block. Vaas, the game’s antagonist and de facto poster boy, is a ruthless slave trading pirate who seems to have no motivation for his brutality other than that fact that he’s criminally insane.

Far Cry 3’s Vaas, Call of Duty: Modern Warfare’s Makarov and all the others who make up the pantheon of Video games’ Criminally Insane Antagonists are for many players the only (or at least the main) exposure they have to any sort of mental illness, and it’s done immeasurable damage to the discussion. Look at any one of the unfortunate but sadly omnipresent mass public shootings in the U.S., at how quickly newscasters and police authorities dismiss these abhorrent actions as a product of garden-variety undefined mental illness.

We aren’t being encouraged to understand and empathize with mental illness, we’re being taught by pop culture to fear it. These villains and madmen are irrational, violent and unpredictable because they are driven by the seemingly autonomous caprice of generic 19th-century Insanity.

It’s no wonder, then, that conversations surrounding these topics are often held at arm’s length, as though we were greeting an extraterrestrial for the first time without having the slightest inkling of what its intentions or behavior might be. As a result, short of trying to understand the effect and impact mental illness can have on people, we seek to distance ourselves from it as much as possible; insanity is the province of Bad People, and they are dangerous and not to be trusted.

We're being taught to fear mental illness, not understand it

The challenge games face in regard to the mental health discussion is how to bring these issues to light without falling into the common traps. That’s not to say that games should avoid the horror genre in its treatment of the topic. The fact is that mental illness is horrifying for those who suffer, and it can drastically affect one’s perception of the world. But to focus solely on the spooky and the irrational is to only tell half the story. Mental illness is severe, but it is far from the death sentence that many of our games [literally] make it out to be.

Developers need to start from the person and work outward, rather that starting with the mental illness and just filling in the gaps. These conditions are parts of a larger, more comprehensive whole, not living entities in and of themselves. Just like patients aren’t defined solely by their ailments, games shouldn’t be shackled to the horrors that these illnesses can wrack on the mind.

Some recent games have made valiant efforts in this regard. The adventure game Actual Sunlight deals with major depressive disorder, but not in a way that leverages the disease as a gimmick. Protagonist Evan Winters is A Depressed Person, yes, but he is also An Employee and A Son and A Tenant, and playing through the game is really a process of stepping back far enough to see how all of these tiles fit together to form the mosaic that is his daily life. That the majority of Evans’ interactions and thought processes are influenced by his depression is simply an acknowledgement of how pervasive and oppressive the disease is to those who suffer from it.

The Twine-made adventure game There Are Monsters Under Your Bed addresses depression, anxiety and body dysmorphia situated within a horror framework. Its encounters, dialogue and text are immensely personal, told exclusively from the perspective of the protagonist and player character. The main thing that differentiates it from similarly structured games like Amnesia is that the mental illness is not used as a device to set atmosphere and create tension — it is the sole focus of the game.

Your illness in There Are Monsters Under Your Bed isn’t there simply to make your run-ins with monsters more frightening, your illness is the monster. The player finds herself locked alone in a room unable to escape as an incredibly apt metaphor for being trapped inside your head as a mental illness sufferer, unable to break out of destructive thought processes.

Approximately 10 percent of Americans are living with some form of diagnosable mental illness

These games are significant because they don’t use their characters as pawns to provide thrills or entertainment to the player. They serve as a window into what living with mental illness is like from the perspective of those who suffer from it. They attempt to actually invoke empathy rather than discourage it, and to remind players that mental illness is as real as it is severe.

Approximately 10 percent of Americans are living with some form of diagnosable mental illness. Unfortunately, we still approach the subject with distance and disdain. Instead of opening up a nationwide conversation to determine how these issues can best be addressed, we choose to keep our eyes closed just enough that we lose sight of the invisible illnesses that affect so many, content to acknowledge their existence only as defined by the skewed parameters of our video games.

As long as we keep employing the same harmful tropes, and refuse to exercise our empathy and actually reach out to those affected with mental illness and instead mystify, or worse, demonize them, so many of us will continue to remain invisible.