Sometimes video games aren’t meant to empower or immerse, but for something much more primal: to scare the crap out of you. Playboy’s Fear and Loading series peers down dark hallways and checks under gaming’s bed to find the games that terrify us, and delves into how and why they work.

The horror genre and mental health issues are no strangers to one another. Tropes like spooky asylum settings and escaped “mental patients” appear in horror games ranging from 1998’s Sanitarium (and some much earlier than that) up through new releases like last year’s The Evil Within, and what feels like every horror game in between. But paradoxically, these games often really suck at actually portraying mental illness in a realistic and compassionate way.

In an article for Polygon, Patrick Lindsay explains the knee-jerk relationship between horror games and mental health: “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.”

Lindsay rightfully takes horror games to task for their harmful and erroneous depiction of mental illness. Constantly representing people who are mentally ill as serial killers, murderers and “psychos” perpetuates the misunderstanding that neuroatypical people are dangerous.

Here’s a fun fact: people who are mentally ill are actually more than twice as likely to be the victims of violence than the perpetrators of it, according to the Canadian Mental Health Association.

But while many horror games fail to accurately portray mental illness, the combination of genre and medium does hold a unique position to create empathy about what it’s like to actually suffer from mental illness. In horror, audiences are used to believing the otherwise unbelievable or questionable tales from the protagonists, and we’re also trained to be frustrated with those who refuse to believe the protagonist. And in games, players identify directly with the characters they control. That’s a potent mix.

I once wrote a personal essay titled, “If I Screamed, Would You Hear Me?” to focus explicitly on why I make horror games about living with mental illness. Sometimes, the only way people will actually listen to you is if you scream loud enough—and boy, can you scream a lot in horror games.


“At first I thought I was sick. But then I realized I’m not. I’m normal,” says the Lodger, the sleep-deprived player character from the 2012 Kickstarter-funded game Knock-Knock.

Knock-knock is a horror game unlike any other I’ve ever played. The premise is simple: you play as the Lodger, a man who cannot sleep and must stay awake (and sane) throughout the night. What seems like an ordinary task is compounded by the creaking, giggling and knocking noises that plague him, emblematic of the character’s struggle with schizophrenia. Retaining your calm and being able to survive the night becomes a trial not of defeating a mentally ill villain, but of learning to cope with the uneasiness of your own mind.

While some of the Visitors (the creatures lurking in the house) are straight-jacket-wearing spooks, their function is radically different from those in, say, Neverending Nightmare, another escape-the-room side-scrolling horror game about mental health. In Neverending Nightmare, these enemies are just that: they are there to physically hurt you and are violent.

But in Knock-knock, their function is thematic: they’re reflections of your own mental struggles, not enemies in the traditional sense. They don’t hurt you; they just make it harder for you to stay sane until morning.

This difference is small but crucial, because the lack of overt violence shifts the conflict from mental illness as a danger to others, to mental illness as a danger mostly to the individual suffering from it.


As with Knock-Knock, the threat of death is removed from The Cat Lady, a horror game released by Harvester Games in 2012. Protagonist Susan begins the game by committing suicide, but through a fantastical (and creepy) alternate reality she’s granted immortality. Anything that would normally kill her causes her to immediately wake up alive and well instead. It shifts the focus onto the way she learns to live, with both herself and the world that surrounds her. As Lindsay writes in his Polygon article, it’s a focus on “rebuilding,” an act those who suffer from mental illness engage with constantly.

“If there’s one thing that Mitzi taught me, it’s that you have to pick yourself up and carry on,” Susan says in the game. “It doesn’t matter that life isn’t fair; it doesn’t matter that you makes mistakes; you fall, and rise again.” The Cat Lady is about this process of hurting and learning to recover from the hurt—a necessary and terrifying process anybody who has experienced mental illness in their life knows all too well.

Compare that to a game like The Evil Within, a big-budget horror blockbuster game released late last year. It trains you to be afraid, rather than understand; to shoot (or stab) first and question why later. It uses an asylum as a (very tired and clichéd) setting to begin the game, and you power up your abilities by going through electroconvulsive therapy (a.k.a. electroshock therapy)—a real life treatment reserved for patients with certain forms of mental illness and one that is very dangerous.

Rather than aiming to create compassionate gameplay, as Knock-Knock and The Cat Lady do, The Evil Within offers these tropes as stylized settings or quirky mechanics to create a spectacle out of mental illness.

This isn’t to say that indie developers are always better at representing mental illness. Downfall (2009), also by The Cat Lady maker Harvester Games, failed to convey an empathy and understanding to what it’s like living with an eating disorder. Ivy Davis, the character suffering from an eating disorder, is treated like an outsider and a burden, and her disorder is reduced to a plot in the story of Joe, the protagonist. Even Joe’s undefined madness feels poorly and vaguely represented, used more for atmosphere and to establish him as potentially more of a villain than a hero.


An operating room from

An operating room from ‘The Evil Within’

Horror games can utilize fear and terror to illustrate the mindframe of those who are suffering, rather than treating people with mental illnesses as enemies or tools with which to create a creepy atmosphere. Games like Knock-Knock and The Cat Lady normalize experiences of mental illness by putting the people suffering—the player-controlled protagonists—on the same playing field as everyone else.

In these games, you’re not the neurotypical player character defending yourself against crazed, unbalanced and monstrous humans (as the stereotype goes). You’re the neuroatypical battling against a world that can be threatening and terrifying and learning to persevere through it.

Characters like the Lodger and Susan are normalized by their positions as player characters and by not being relegated just to the position of setting or villains. It repositions them from being outsiders, others, to a place of normalness—where they belong.

Kaitlin Tremblay is a writer, editor, and gamemaker. As someone who struggles with both depression and disordered eating, most of Kaitlin’s writing and gamemaking focuses on dispelling misunderstandings about mental health. You can find her games and writing at her website and on Twitter at @kait_zilla.