The representation of mental health conditions and neurodivergence in video games has so often been a horror story - especially in horror stories. This likely isn’t controversial to anyone with even cursory media literacy given the horror genre’s past with misogyny and physical disabilities.

This topic is more complicated than an inevitable changing tide towards more positive representations, however. The past few years have led to many interesting conversations on content warnings, accessibility, and censorship.

It’s a pertinent question for ever more inclusive societies and spaces - does the responsibility to not encounter triggering content lie primarily with audiences or media creators?

Whilst it might initially seem reasonable to expect a vulnerable player to be suitably wary of the likely content of a horror game or to do the due diligence that they can, many developers are undoubtedly underutilizing a whole host of tools at their disposal to improve accessibility through better informed representation in the first place and/or more flexible content customization options and comprehensive warnings.

What can horror games do for players?

The gulf in current philosophies is wide. On this spectrum we see everything from little to no efforts on this front to the more nuclear option of erring on the safe side with blanket removal of content.

From the very localized controversy surrounding, but otherwise lack of coverage around Bloober Team’s The Medium and its ‘misguided’ messaging on intergenerational trauma to the long anticipated Psychonauts 2 taking itself a deep dive into trauma, more and more we’re tacitly presented with the differing approaches and attitudes of creators, platforms, and their bespoke audiences too.

As with the video game industry’s cyclical difficulty accessibility disc1se, the oft-made argument that not all media needs to be universal wrongly assumes that the horror genre would be of no attraction or value to certain groups. One anonymous survivor of trauma and abuse I spoke to similarly indicated they actually benefited from engaging with horror games.

"I find that I enjoy horror games that have the implications that things can get better," they said. "Or even a game with characters that are truly relatable. I find these things cathartic." Representational or content options adjustments could well give the most vulnerable players more confidence to access media that helps them.

Whilst provocative and triggering content is in no way exclusive to the horror genre, its relationship with mental health could be said to be markedly harmful. In the domain of psychological horror mental health can be cast as the villain, perhaps even a physical monster or hellscape at that. Otherwise, it can be represented in wildly inaccurate and caricatured ways.

This only works to exacerbate the stigmatization of mental illness according to Dr. Rachel Kowert, the research director at the game industry mental health non-profit Take This, "Our cultural values take cues from the media that we consume," she tells me. "That is, how the media portrays different groups of people conveys a sense of cultural value that we then absorb and integrate into our collective thoughts, values, and beliefs."

"The content of our media conveys a sense of cultural value by reflecting our attitudes, beliefs, and priorities and our cultural values can shift based on the messages in the media we consume." Such effects range from cultivating new thoughts and ideas to reinforcing stereotypes.

Raz from Psychonauts 2 makes a point to ask for consent before invading characters' minds.

If these are based on exaggerated and inaccurate representations - for example, that people with mental health challenges are more likely to be a perpetrator of violent crime than a victim of it - this might only further ingrain stigmatization. "As media content holds the potential to shape the way we perceive and interpret the world by shifting an individual’s thoughts and behaviors or shifting cultural attitudes, it is important to analyze and critique the content of these messages, particularly when it comes to mental health," she adds.

Media consumption is a potentially damaging interaction with both what we initially bring to it and take from it, then.

So how can game developers and writers best approach a social and cultural minefield like psychological horror whilst being cognizant of the effect of representing real-life conditions and the implications of narrative themes? In other words, what is good representation anyway?

Mental health and horror have gone hand-and-hand for years

Dan Salvato, developer of Doki Doki Literature Club!, believes that horror’s bad relationship with mental health is not at all inevitable. "The defining features of the horror genre do not inherently necessitate that any portrayals of mental health conditions must be what makes the game scary," he says. "Likewise, when conditions do contribute to what makes the game scary, they do not have to be one-dimensional caricatures in order to preserve the defining characteristics of horror."

However, a (healthy) degree of inaccuracy might be given how individually mental health can manifest. "To be honest I’m not entirely sure any entertainment medium can accurately portray mental ill health or trauma," Tim Follin, the developer behind At Dead Of Night tells me. "The fundamental problem is that all stories are in essence a way to serve up a bite-sized, neatly packaged, simplified version of the truth. People are infinitely complex, so any attempt to tell a story about mental health, which I think reveals the most complex aspect of human nature, is always going to fall short."

One interesting common thread from the conversations I had with developers was that rich character writing was so much more important than some intentional tipping of the scales towards a more neutral or positive depiction of mental health. "I think if a creator deliberately sets out to depict a particular mental illness or condition, they’re immediately stepping into a huge minefield," says Follin.

"No matter how well-intentioned, it’s extremely hard to make work, because no one’s personality is ever defined by their diagnosis; it’s defined–or rather, revealed–by how they respond to it."

Cornelia Geppert, writer of Sea of Solitude, and Ido Tal, producer of In Sound Mind, weren’t as concerned by this latent minefield, so long as any depiction is a considered one. For Geppert, it was most important for a writer’s opinions on sensitive topics to be able to still breathe whilst considering representation. "It's a fine line to walk," she said. I think it is essential that artists can express themselves freely. That means to not tread themes in a neutral or only positive way but through the eyes of the artist, how they feel about it!"

For Tal, an intentional depiction could still be an opportunity. "The misuse of mental health in different mediums like movies and games in the past is the reason why creators should take a closer look and improve upon its depiction rather than running away from it."

"Whilst our team never set out to right that wrong directly with In Sound Mind, it’s still our responsibility to treat the subject with care," continues Tal. Mental health is a complex part of our lives, and it’s important to us to treat the subject with respect while promoting acceptance and understanding."

Salvato, like Follin, however, is wary that having a character defined by a mental health condition—even if accurately presented—could be exactly what not to do. Repeating the same mistake from the other direction. "Neurodivergence isn’t a character trait—neurodivergence is a human reality that has a mutual relationship with character traits."

"It’s just about making characters who create empathy in the audience through their relatable internal and external challenges. And the more you isolate that character’s identity to be solely about some tokenized or romanticized trait, the more you’re harming representation by straying from the reality that we’re all human beings."

An intentional depiction could itself risk generalizing mental health conditions that present incredibly individually and inadvertently dehumanize characters by not writing them with personalities first, then. Is it still possible to set out to write mental health as a smaller part of a larger character, however?

"We went to great lengths to show that one is not defined by their circumstances or their mental health," Tal tells me. "It's not necessarily the key in every game, but it was an integral aspect in our case."

According to Follin, this is also where some audience responsibility and media literacy comes in. The central character in At Dead Of Night was construed by a small number of players as a portrayal of Dissociative Identity Disorder (previously Multiple Personality Disorder) or DID.

"As far as I was concerned the character was a theatrical and symbolic depiction, similar to Jekyll and Hyde. Also, the character had fundamental features that distinguished him from someone with DID; for instance DID is defined by an amnesia between ‘alters’ (separate identities) whereas my character was in constant dialogue with himself, in much the same way we all have internal debate with ourselves when deciding between opposing courses of action."

It’s a similar situation, Follin says, to the criticism Mar Haddon, the author of the book ‘The Curious Incident of the Dog in the Night Time,’ faced for his ostensibly autistic protagonist. Mark has denied this interpretation and explained that he simply created a character with a unique personality and certain personality traits and difficulties.

Only when seen through the lens of being a deliberate portrayal of a particular diagnosis is it a potential cause of damaging representation. If it’s the case that an audience widely or even in part reads a character this way, does this mean writers need to be equally careful about close analogues to as well as deliberate depictions of real conditions? Follin thinks not. "It'd be ridiculous to suggest the author is somehow irresponsible for creating the story because some people misread it."

Like the developers I talked to, Dr. Kowert agrees that a multidimensional approach to portraying mental health in games is one of the most important thing a creator can do to improve representations. "

This means developing representations of mental illness as fully realized and essential components to a character, narrative, or environment," she tells me. "These representations have depth and dimensionality and examine the experience of mental illness from multiple perspectives. Three-dimensional representations reflect authentic experiences but do not necessarily need to be true-to-life in terms of design."

Some developers are writing from experience

Beyond research informing depictions, for Geppert, authenticity from experience was key to avoiding any perception of exploitation and insensitivity in her game. "I wasn't thinking about what kind of mental health story I want to tell and then started to research about it," she says. "I simply expressed my inner feelings. I told stories I lived through myself or heard from other people about. I filtered everything through my mind and put it out there for you all to experience."

"That's the simple story behind how Sea of Solitude came to be. With this natural development, you can hardly fall into a trap of exploiting anything."

Geppert agrees that this degree of intentionality in depictions is not a very natural writing process. "Let's be honest, nobody for whom education is the priority would try to achieve their goal by creating a piece of horror entertainment. I think if creators are completely truthful with themselves, the idea comes first and the justification comes second – more often last."

Said ‘research’ behind mental health depictions certainly encapsulates a range of approaches whether intentional from the outset or post hoc justified. For Geppert with Sea of Solitude this simply meant giving the script a second pass. I got strong pushback from people as details were too disturbing for many even when they had been drawn from real life. I took that feedback seriously and toned the story down a lot!"

Salvato agrees that a second pass on a script can be key. "Involve people in development who are intimately familiar with the character traits that you’d like to portray," he advises. "Fiction is communication. What do you, and/or others who are intimately familiar with these traits, want to communicate to the audience?"

This was the case with In Sound Mind too. The game's creators consulted patients and mental health experts on the topic of psychosis, similar to how Ninja Theory did when it made Hellblade: Senua's Sacrifice.

Tal told me that a more granular consultation of experts can be beneficial. In this case, they did so by polishing their script by working with actual therapists. "To start, you need to accept that most likely you don’t have all of the answers right away. When you incorporate something that is a significant factor in people’s lives, such as mental health, you have to research and learn."

"One example of the things we wanted to make sure we get right is the patient-therapist sessions, which are short audio logs you can hear in and out of levels, setting the tone. We were advised through suggestions like 'instead of interrupting the patient here, I would let her speak' or 'this one is an unusual response for a therapist, here’s what I’d do if I was facing a similar patient.' So we made the changes where necessary and re-recorded parts as needed."

As well as consulting experts and second passes of scripts, playtesting can also be a useful tool. "You need to be able to read the room," says Tal. "In Sound Mind is a psychological horror game, but one of the things we quickly found is that players like when we break the tension every now and then. Adding humor is a delicate task that tipped the game’s direction, adding depth and memorable moments to the characters and their stories. In turn, we’ve balanced the pacing of both the darker moments and the lighter ones. Playtesting feedback is one way to find this balance."

Giving players tools to cope with the nightmares

Beyond better representation through writing and the research that informs it is where this topic meets the wider discourse on content warnings and accessibility. What more can developers otherwise do to approach such sensitive subject matter whilst acknowledging a potentially vulnerable audience?

"Comprehensive warnings and the ability to 'skip over' triggering content would be a good place to start in terms of improving the way mental health stories are told through games," says Dr. Kowert. This is something Salvato wholeheartedly agrees with, having implemented warnings in his rerelease of Doki Doki Literature Club Plus!. "Content warnings are a fantastic optional accessibility feature. Millions of people, more than we see, feel safer when using content warnings."

There are arguments that such detailed content warnings might well spoil narrative twists like those seen inThe Medium orTwelve Minutes. Whilst there have been several efforts to create external databases to detail various triggers for players, these remain thin on the ground and anything but comprehensive. Combined with a lack of standardization in the usage of warnings/options and otherwise their quality when employed by developers, this leaves a big accessibility gap.

"Trigger warnings are so important," Dr. Kowert tells me. "Games are immersive experiences that can have a real impact on players, especially when it portrays serious topics and themes related to mental health. As the largest form of popular media on the planet, researchers and designers have an obligation to better understand how media messages can shape the popular discourse in and around this important topic."

Much like issues of accessibility in controls, difficulty, color settings, and more, Salvato too sees content warnings as a logical extension of the wider push for video game accessibility. "Ultimately, players deserve control over how they want to be exposed to sensitive content, and optional content warnings enable more players to enjoy the story that we wrote. There is not one 'best' way to enjoy the game; everyone has their own preferences and needs. 

Developers have the opportunity to honor these preferences and needs, to ensure that players are able to play in a way that feels right for them." For Geppert this involved reaching out before Sea of Solitude was even released. "Even before the release of the game we talked about the themes that would occur in the game to make sure people can decide if it is something they want to play!"

Whilst Doki Doki Literature Club! saw a rerelease with added content options, Sea of Solitude fascinatingly saw a complete rewrite for its Director's Cut. "Most of the feedback from players who could relate to the themes were overwhelmingly positive. Many professional critics and players who couldn't relate to the themes, however, said that they found the stories boring and too in your face. I talked with many people, in private but also industry giants and other professionals, about how extremely torn the feedback on Sea of Solitude is. It's still a bit surprising for us all."

For the Director’s Cut, Geppert had senior writer Stephen Bell mostly alter wording and the expression of said themes. However, in one significant case an element of the story and its representation that had been drawn from Geppert's own life was reevaluated. "The last Family monster you meet in the game is the boyfriend monster. The boyfriend suffers from depression and he step by step draws away from the main character, Kay."

"When I wrote it I had gone through this in my real life and wrote it in a pretty romantic way. When Stephen looked at the story and asked me about it he carefully mentioned that he clearly sees the abusive behavior of the boyfriend towards the main character. I now know too that I was in a relationship with a mentally abusive man, but back in the day I couldn't or wouldn't want to see it this way…it was absolutely incredible that Stephen got that instinctively right! He is an incredible writer who knows how to tackle mental health themes."

Equally, for all the bad of a mishandled representation, the plasticity of our brains to respond to good representations is significant. "Seeing and experiencing a certain pain or struggle that isn’t necessarily yours is a way to learn and empathize," says Tal. "When I played through Senua’s struggles in Hellblade, I was able to see there are human emotions which I didn’t understand before. Or when I saw the scenes in Midsommar where Dani goes through panic attacks, it reinforced that some people are dealing with mental and physical pain that is vastly different from my own experiences. Both were fantastic entertainment, but they also helped expand my understanding of other people’s experiences."

Dr. Kowert agrees that the cultural and social good is in promoting understanding through empathy. "Accurate portrayals can help change perceptions and ideas in and around mental health like has often been discussed in relation to Hellblade. Many have noted that playing that game helped them better understand friends, family, and other loved ones who are struggling with similar symptoms to Senua."

Where is horror and mental health in games headed next?

For all of the creators, despite some diverging methods and perspectives, all thought there was a huge social and cultural good to improving mental illness portrayal. "Yes, I think most media should feature human beings," as Salvato puts bluntly.

For Geppert the results are very evident. "Hundreds of fans wrote to me afterwards to say how, in a deeply positive way, Sea of Solitude changed their life. Many told me how they finally didn't feel alone anymore with their issues."

"Many even talked about how they actively started to change their life to the better when they finished the game. For example many started to go to therapy to work through what they deal with and finally aren't embarrassed to do so anymore. Others told me how they for example finally found the strengths to end their abusive relationship."

There were also things they all thought they could improve on. "In the future, I would like to form new working relationships with all kinds of individuals with diverse backgrounds, qualities, and personal experiences," says Salvato. "By taking this step, we have a chance to share an even greater span of emotion and personal communication through our storytelling that reaches beyond just my own experiences."

"I just want to write stories about the true human experience, especially for qualities or identities that are underrepresented in media. That will be a part of my future games."

Follin and Geppert both learnt a lot from the writing processes and feedback from their games. "I won’t stay away from creating interesting characters because they might be construed as having particular psychological conditions," says Follin. "But I will try to make sure that their personality can’t be construed as a negative stereotype of a particular condition. And I’d certainly avoid creating a character with a known condition deliberately." 

"Sea of Solitude was the first complex story I ever wrote," says Geppert. "And I feel it’s not as elegant as if a senior writer had written it. Well, this is what I took from the professional critics that bashed the writing for its simplicity! It was the most wonderful experience to watch Stephen Bell rewrite the same story but in his words. I learned a hell lot for the next game."

But for Geppert some stepping back from sensitive topics is necessary for the moment. "Developing Sea of Solitude was an extreme experience as I lived through some of the stories while developing the game. So we want our next game to be something where we as developers can regain our energy again. Something more fun, more lighthearted, and smaller in terms of the number of heavy topics!"

For Tal too, there is an advantage to having had that experience in handling sensitive topics previously, especially when recognising the responsibility that comes with it is part of the learning process. "We wanted to create a fun horror game, with a lot of passion for old-school first-person puzzle mechanics, and in the process we recognized our platform and responsibility in its depiction of mental health."

"I don’t know if we got everything right, but I can say that people in our team care. And I think it takes teams that care to eventually tip the scales and progress beyond past stigmas in video games."