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The Monstrosity of Stigma: Mental Health Representation in Video Games
Kelli Dunlap1 and Rachel Kowert2
1American University, Washington D.C., USA
2Take This, Seattle, Washington, USA
KEYWORDS: video games, mental health, culture, psychopathology, mental illness, game
development
Media content (e.g., television, film, video games) simultaneously reflect societal attitudes,
beliefs, and priorities as well as actively shift cultural values based on the messages in the media
we consume. These effects can range from cultivating new thoughts and ideas to reinforcing
stereotypes. At the cultural level, mass produced messages (like those in the media) provide
many of the raw materials of our consciousness and influence our perceptions. 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. As the
dominant media of the 21st century, the way mental illness is portrayed in video games is of
particular interest and the focus of this discussion. This paper will discuss the monstrosity of
mental health stigma in games by exploring the ways mental health is portrayed in video games,
from obvious tropes to subtle environmental cues underpinned by insidious cultural assumptions.
This will also include a discussion of how mental health and illness representation in video
games span character development, narratives, environments, and game mechanics. While the
most well-known examples also tend to be the most exaggerated (e.g., the psychopathic villain,
the insane asylum setting, etc.), the true monstrosity of mental illness lies in those
representations that are subtle or subconscious; portrayals that prey upon and exacerbate our own
fears but do so largely out of awareness of the player and developer alike. We hope these
discussions help raise awareness within the gaming community about the ways mental illness is
incorporated in gaming spaces - from the overt to the subtle - and encourage a greater
understanding of the ways psychopathology has become culturally ingrained within this
medium.
Introduction
Stories convey the values and beliefs of the societies that create them. From the spoken tales of
the ancient Greeks, European romantic poetry, and Americana folklore, storytelling has always
been a place to explore and educate about a wide variety of topics.
As the dominant cultural form of the 21st century (Johnson, 2019), video games have become
key storytellers of our generation. Like traditional forms of storytelling, the content in video
games convey the values and beliefs of the people and societies that have created them. As such,
they have rapidly developed into spaces for exploring and telling stories about a range of topics,
including mental health.
Mainstream video game development has been telling mental health stories for decades. Starting
as early as 8-bit adventures on the original Nintendo gaming system, with games such as Maniac
Mansion (Nintendo), to the beautiful immersive worlds of the 21st century, such as the award-
winning 2018 action-adventure game Hellblade: Senua’s Sacrifice (Ninja Theory, 2017). More
recently, the democratization of game development via broadly accessible tools like Unity and
the ability to self-publish on sites like Itch.io have allowed for smaller teams (or in some cases,
individuals) to produce mental health experiences through games. Games such as What Remains
of Edith Finch (Annapura Interactive, 2017) and Sea of Solitude (Jo-Mei Games, 2019)
immediately come to mind.
While some of the above examples highlight well-told, nuanced portrayals, most of the stories
that have been told about mental health and illness through games have been characterized by
inaccurate tropes and gross overgeneralizations. This is problematic, as research has found that
our collective beliefs about mental health are largely generated and shaped by media messages
(Ma, 2017). Media content not only conveys a sense of cultural value by reflecting our attitudes,
beliefs, and priorities, but our cultural values can shift based on the messages in the media we
consume. These effects can range from short-term impacts, such as cultivating new thoughts, to
long-term change, such as stereotype reinforcement. As described by Gerbner (1963), mass
produced messages from the media “provide many of the raw materials of our consciousness and
of the terms of our perceptions” (p. 39). 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.
While the cultural impact of traditional media (i.e., television and film) in relation to mental
health portrayals has been widely discussed (for a review, see Pirkis, Blood, Francis, &
McCallum, 2005; Stuart, 2006), the representation of mental health and illness in video games
has been less widely investigated (for a review, see Dunlap, 2018). This is despite the fact that
video games are the dominant cultural form of the 21st century, with recent reports indicating
215 million Americans alone play video games (Entertainment Software Association, 2020). This
paper will explore the monstrosity of mental health stigma in video games by examining the
ways that mental health and illness are portrayed within these spaces. The primary aim is to raise
awareness about the ability for video games to shape cultural discussions through their unique
storytelling, specifically in relation to the ways mental health and illness has been portrayed in
these media spaces.
Games as a unique form of storytelling
One of the reasons that mental health portrayals in video games have been less explored may be
because they are a unique and multifaceted form of storytelling. Unlike more traditional forms of
storytelling, such as television and film, they have an added element of dynamic interactivity
between the player and the game world. As an interactive medium, video games provide unique
affordances in the ways they convey cultural information (Madigan, 2015). Depictions of mental
health and illness in gaming spaces are not limited to the characters, settings, and narratives, but
can also be portrayed through in-game mechanics and influenced by player decisions (Anderson,
2020; Dunlap & Kowert, under review.). The ways in which mental health can be portrayed in
games is discussed the more detail below.
Mental health representation in games: Characters, Settings, & Mechanics
The multifaceted ways in which mental health and illness can be represented in games sets them
apart from traditional forms of media that are limited by a lack of interactivity. The
multidimensionality of these messages is explored in more detail below.
Characters & Tropes. The characters of any particular game set the foundation for the
storytelling of the narrative. Their experiences are the vehicle that transports the player into new
worlds and experiences through the gaming space. Like traditional media, video game content
conveys cultural values and beliefs in and around mental health through character development.
Unfortunately, this has most often come in the form of caricatured portrayals and tropes.
Generally speaking, the media has historically portrayed characters with mental illness in
negative, exaggerated and (largely) inaccurate ways (Aguina, Madden, & Zellmann, 2016; Klin
& Lemish, 2008). Research has found that video games portray many of the same mental illness
tropes found in traditional film and television, such as the homicidal maniac, rebellious free
spirit, the specially gifted or enlightened, female patient-seductress, narcissistic parasite, zoo
specimen (Hyler, 2003), the simpleton, and the failure or victim (Pirkis et al., 2005). For a
summary of these tropes, see Table 1.
[INSERT TABLE 1 ABOUT HERE]
All of the classic tropes discussed can be found in video game characters; however, their
prevalence varies. Shapiro and Rotter (2016) assessed the prevalence of these tropes across the
top 50 best-selling video games from 2011 and 2013 and found 69% of characters with mental
illness portrayed in these games acted in line with the homicidal maniac trope, 2.4% the
narcissistic parasite, 4.7% as zoo specimens. A significant proportion did not fit in a specific
category (23.8%) but displayed psychologically distributed attributes, such as paranoia.
The homicidal maniac, the most common depiction of mental illness found in games, is a trope
wherein violence is paired with madness, insanity, psychopathy, or other psychological
instability (Hyler, 2003). This is somewhat unsurprising as the pairing of mental illness and
violence is a problematic myth dating back to antiquity. In Greek mythology, for example,
Maniae were a set of spirits that personified madness and insanity and frequently teamed up with
their sister Lyssa, the goddess of rage and rabies (Kromm, 2002). The homicidal maniac trope
was also utilized in the early days of film, with 1919’s The Cabinet of Dr. Caligari being the
earliest known example (Sabo, 2016).
One of the earliest examples of this trope in video games can be found in the primary antagonist
in Maniac Mansion, a graphic novel video game developed by LucasArts and released in 1987
for the Nintendo Entertainment System. The game’s antagonist, Dr. Fred Edison, is a “mad
scientist” who is trying to obtain human brains for use in experiments. Dr. Fred and the other
members of his family who inhabit the mansion are single minded in their desire to kidnap,
imprison, and murder the playable characters in the game.
Games from the role-playing genre have also often relied on antagonists who fall within the
homicidal maniac trope, such as Kefka Palazzo from Final Fantasy VI (Square Enix, 1994).
Kefka is chaotic, unpredictable, and seemingly driven to cause destruction simply for the sake of
destruction itself. He has an unquenchable thirst for chaos and inflicts suffering unto others for
the sake of his own amusement.
These types of portrayals are just as common and problematic in contemporary games.
Cyberpunk 2077 (CD Projekt RED, 2020) features several characters stricken with
cyberpsychosis. According to the Cyberpunk Wiki, this is a mental illness based vaguely on
dissociative symptoms and caused by excessive cybernetic augmentation to the body.
“Cyberpsychos” may develop symptoms of kleptomania, dissociative identity, or compulsive
lying, however the most common manifestation of cyberpsychosis is enacting violence toward
other beings (Pondsmith, 1990). Ellis Carter and Zaria Hughes are two examples of Cyberpunk
NPCs whose cyberpsychosis triggered acts of extreme violence.
Some manifestations of this trope are less obvious than others. In Halo: Combat Evolved’s
(Bungie, 2001) level 343 Guilty Spark, the player discovers a distressed NPC Marine whose
barks include, “I'll blow your brains out! Get away from me!” and “The monsters are
everywhere!” It is later revealed that this Marine survived a traumatic encounter with an alien
species and is experiencing intense trauma. However, what sets “AWOL Marine'' apart from
other Marine NPCs is that he’s the only human NPC that intentionally harms the player-
character. The AWOL Marine shoots a pistol and deals damage to Master Chief, the game’s
protagonist, and is capable of killing him. Put another way, the AWOL Marine is the only human
character who acts violently toward Master Chief and his violence is motivated by severe
trauma.
While the homicidal maniac has been the most widely used and is perhaps the most obvious
mental illness trope across media including games, numerous other mental illness tropes can be
found in both classic and modern video games.
For example, Javik in Mass Effect 3 (Electronic Arts, 2012) exemplifies the Narcissistic Parasite
trope via his pathological self-centered and aggrandizing statements, fixation on his own issues,
and belittling interactions with others. Similarly, Poison Ivy in Batman: Arkham Knight
(Rocksteady Studios, 2015) is the epitome of the Female Patient as Seductress trope as she
wields her sexuality as a weapon, reinforcing that female sexuality is duplicitous and dangerous.
It is important to note that these character tropes are not limited to the personality factors of a
character but can also be portrayed in more auxiliary ways, such as through costume design. A
recent example of mental illness being used as costume and set dressing occurred in 2019 with
the announcement of Sigma, a new Overwatch (Blizzard Entertainment) character. Sigma was
depicted in full-battle dress but without shoes. A character artist at Blizzard, the publisher of
Overwatch, described the design decision: “We decided to keep the feet bare to sell the ‘asylum’
look a bit more; in many institutions, patients aren’t allowed to have shoes because they may
cause harm with the laces.” (Hernandez, 2019). It was later revealed that Sigma’s backstory is
that of a scientist who survived a traumatic accident and, as a result, was deemed unsafe and
detained under the name ‘Subject Sigma.’ Isolated and unable to control his powers, he retreated
into his own mind only to be sprung from his psychiatric confinement to be used as a puppet-
soldier by the game’s primary antagonist group. In other words, Sigma was purposely developed
to represent someone who has experienced significant trauma, was detained in inhumane
conditions and, to reinforce the narrative of his mental instability, denied shoes as a wink and a
nudge to players that he is, in fact, mentally unstable. This representation fits within the classic
Zoo Specimen trope and reinforces the (erroneous) stereotype that people with mental illness are
wildly unpredictable and dangerous as well as the idea that mental health institutions are
characterized by brutal and inhumane nature treatment of their patients.
Mental Health Settings & Treatment. Mental illness portrayal in video games is not
limited to character design and narratives. Game environments, settings, and ephemera that flesh
out the world also represent and convey information about the role and meaning mental illness
takes in the game world. The most obvious example of this is when the game itself takes place
within a psychiatric setting such as insane asylums or therapist offices. Horror games are
notorious for using asylums as game settings; Sanitarium (Dreamforge Interntainment, 1998),
Manhunt 2 (Rockstar London, 2007), The Inpatient (Supermassive Games, 2018), and Asylum
(Senscape, upcoming), just to name a few.
Any location can be made unsettling by turning down the lights and adding jump scares, but by
using psychiatric hospitals game developers utilize a cultural shortcut which preys upon the
inherent fears and preconceived stigmas people hold about such institutions. Using asylums as
settings and backgrounds primes players to be afraid, to expect violence and terror before
gameplay even starts. Think back to the games you have played in the past that take place in such
settings. Have you, as a player, ever woke up in a psychiatric hospital and had something good
happen? Probably not.
Similar to psychiatric hospitals, games which portray mental health treatment through outpatient
settings or interactions with mental healthcare professionals are often problematic. These types
of portrayals are few and far between, yet often particularly monstrous. For example, Harlan
Fontaine, a celebrity psychiatrist in L.A. Noire (Rockstar Games, 2011), uses his prescription
privileges to deal drugs and intentionally get his clients addicted to morphine. Similarly, Angus
Bumby from the Alice (Spicy Horse, 2011) series uses his position as a psychiatrist in an
orphanage to mold traumatized orphans into child prostitutes and engage in pedophilia. By
comparison, Grand Theft Auto V’s (Rockstar Games, 2013) psychologist Dr. Isaiah Friedlander
seems almost wholesome in comparison as he merely neglects and extorts his clients. While it
would be ethically dubious for a game to portray authentic interactions with an in-game
therapist, there exists a wide range of alternative portrayals that do not reinforce existing
misconceptions and distrust of the mental health professionals and the problematic or
psychopathic psychologist trope.
Less obvious environmental representations of mental health and illness through the game setting
include the depiction of related artifacts, such as straight jackets, psychotropic medications,
psychological procedures (e.g., electroconvulsive shock therapy).
Mechanics. Mental health themes embedded in the mechanics of the stories told through
digital games is what sets them apart from traditional media. While the use of mechanics to
convey information about mental health may be less obvious than characters or setting, they
perhaps have the most significant impact on the ways in which mental illness is portrayed
through this digital media.
Sanity meters are a classic style of mental illness representation in games and date back to
tabletop roleplaying games of the late 20th century (e.g., Call of Cthulu, 1981). The sanity meter
mechanic tracks a character’s descent into madness or mental instability. Much like a dipstick,
the sanity meter provides feedback to the player about how much “sanity” they have left. Various
audio and visual cues are used to depict a loss in sanity, such as distorted vision and muffled
audio. Within games, sanity meters are frequently found in horror and survival games and
examples include Indigo Prophecy (Quantic Dream, 2005), Amnesia: The Dark Descent
(Frictional Games, 2010), Don’t Starve (Klei Entertainment, 2013), and Darkest Dungeon (Red
Hook Studios, 2015).
Darkest Dungeon is one of the more complex examples of a sanity meter mechanic being
utilized within games. They use a stress meter as a core game mechanic that, when maxed out,
causes players to develop either an “affliction” or “heroic bonus”. Heroic bonuses allow the
player to protect themselves and their party against damage and stress for a short period.
Conversely, afflictions significantly hurt the party and the player. A character with an affliction is
one who suffers and is both a burden and detriment to their team. For example, the “hopeless”
affliction is described in the Darkest Dungeon Wiki Guide as, “A character will say pessimistic
things, causing the stress of your party to increase. They will also attack themselves, refuse to be
healed, and skip their turns.”. It is worth noting that the concept of the heroic bonus could,
ostensibly, be seen as analogous to post-traumatic growth (a theory describing positive
psychological change following a traumatic event, (a theory describing positive psychological
change following a traumatic event, see Tedeschi & Calhoun, 2004); however, that is not made
particularly clear through the use of this mechanic. Ultimately, the procedural rhetoric of the
sanity meter in Darkest Dungeon underscores that the value of someone’s mental well-being
comes down to their usefulness and productivity.
Rather than sanity being an observable “meter” in the user interface, it can also present only as
disturbed or distorted perception within the game environment or gameplay itself. In Alan Wake
(Remedy Entertainment, 2010), the story hinges upon the titular character’s retrograde amnesia
and alcoholism to intentionally create narrative uncertainty and employs visual effects such as
blurred screens and disorienting flashbacks to generate in the player the same confusion as Alan
Wake himself experiences. Another example is the early 2000s horror game Eternal Darkness:
Sanity’s Requiem (Silicon Knights, 2002), wherein players experience odd or disturbing feedback
based on their level of sanity. This includes the appearance of spiders crawling across the
player’s television screen and a save menu that reads “Are you sure you want to delete all of
your saved games?” with only “Yes” and “Continue Without Saving” as options. These types of
fourth-wall experiences are intended to further immerse players and possibly evoke feelings or
thoughts related to questioning their own perceptions of reality.
Game mechanics also procedurally back up a game’s mental illness-related narrative with the
removal of agency or ability. The goal of such a removal in mental health-related games is often
to enforce a feeling of helplessness or frustration in the player, supposedly mirroring the
emotional experience of managing a mental illness. For example, Depression Quest (The
Quinnspiracy, 2013), a Twine-based narrative game, limits a player’s palette of available
response options based on previous decisions that either worsen or improve the protagonist’s
mental health. A similar mechanic can be found in Episode 2 of Life is Strange (Dontnod
Entertainment, 2018) the player is confronted with the potential suicide of Kate Marsh. Up until
this point in the game, protagonist Max Caulfield has been able to reverse time to prevent terrible
things from happening to her and her friends. However, once on the roof of the school and face
to face with Kate her power runs out. Players are presented with dialogue options which, if
correctly selected, will convince Kate to step down off the ledge to safety. Although, if the player
gives too many incorrect responses, Kate will walk off the roof and die by suicide. Given that the
core mechanic of the game is the ability to manipulate time, the removal of that ability in this
moment is a clear design decision to invoke additional anxiety and tension in the player. Suicide
is the second most common cause of death in teens and young adults in the U.S. (National
Institute of Mental Health, 2021) and intense guilt and self-blame are common experiences for
those who lose a friend or loved one to suicide. “Why didn’t I see the signs?” or “I should have
done more” are common refrains. The game requires players to play through this sequence if
they want to continue on in the game, no skipping or opting out permitted, meaning that players
must confront potentially triggering content without content warning or alternative path forward
all in the name of a more “intense” player experience. This presents significant ethical concerns
wherein the emotional safety and well-being of the player appears to be given less importance
than a moment of gameplay and especially concerning as Life is Strange is frequently cited as a
game that positively portrays mental health.
Impact of digital games on mental health
From obvious tropes of psychopathic villains to more subtle, insidious forms of mental health
portrayal, video games are shaping the narrative in and around mental health. Exaggerated,
inaccurate, and stigmatized representations of mental health and illness in the media, and games
in particular, is concerning because it can shape and shift cultural attitudes about these topics.
This is most notable in relation to reinforcing stigma about mental illness and treatment through
stereotyping.
Stigma about mental illness is primarily generated and shaped through stereotyping, which often
comes from media messages (Adler, A. K., & Wahl, 1998; Ma, 2017; Stuart, 2006; Weiss, 1994).
For example, research has found that exposure to negative media portrayals of mental illness is
linked to stereotyped perceptions of the mentally ill (Ma, 2017; McGinty, Webster, & Barry,
2013; Stout, Villegas, & Jennings, 2004) and a reduction in help seeking behaviors for those
struggling with mental health challenges (Pirkis et al., 2005; Stuart, 2006). Heavy media
consumers have also been found to have less tolerance for mental illness than less active media
consumers (Granello & Pauley, 2000). Mental illness stigma can also lead to increased
marinization (i.e., an “us vs them” attitude) and discrimination, both of which have long-term,
real-world consequences. For example, stereotypical beliefs about mental illness have been
found to directly contribute to reduced job and housing opportunities (Link, Struening, Rahav,
Phelan, & Nuttbrock, 1997; Stuber, Meyer, & Link, 2008; Wahl, 1999).
In relation to mental health representation in games, journalists have critically discussed the
more overt and offensive portrayals specifically. A 2014 article entitled “Gaming’s favorite
villain is mental illness and this needs to stop” discusses the tendency of games to depict
mentally ill characters as “broken” and “less than human” (Lindsey, 2014). This is important, as
it illustrates how the ways mental health and illness are portrayed in the media, including digital
games, perpetuates the monstrosity of stigma around mental health. The prevalence of these
stereotyped and caricatured representations has also been noted in research. In their 2016
analysis, Shapiro and Rotter found that just under 1 in 4 of the top selling video games between
2011 and 2013 depicted one or more mentally ill characters. Also, as previously noted, of the 42
individual characters that were identified as portraying mental illness, 29 (69%) acted violently
and in line with the homicidal maniac trope. It is worth noting that these initial explorations of
mental illness representation have been limited to examining characters only; the exclusion of
non-character portrayals such as game settings, environmental items, and mechanics, suggests
the actual prevalence of mental illness in games is likely much higher and, possibly, less
prevalent in conscious awareness.
Conclusion
The way that culture represents mental health through media matters and the monstrosity of
mental health stigma is readily apparent in digital games. This is problematic as stigma around
mental health and illness is a huge obstacle to treatment and has been associated with increased
stereotyping and various forms of discrimination. This is particularly relevant in the case of
digital games as they are the most popular form of entertainment in the 21st century.
The aim of this paper was to draw light to the ways in which mental health and illness are
portrayed in digital games and to highlight the role that media can play in being an ally in
challenging public perception of mental health and mental illness by projecting more accurate
representations of mental health (Stuart, 2006). We hope that this paper inspires game scholars,
developers, and designers to be more cognizant of their biases and how these portrayals can
impact the cultural discussions about mental health and illness in digital games. The creation of
video games is the result of intentional design. It is this design process that is the key to
understanding current cultural values as well as creating cultural shifts through the content that is
created. Awareness of the challenges of mental health representation in games is the first step
towards change.
Moving forward, our hope is that we can have a more nuanced understanding and approach to
representation of mental health and illness in digital media (for more on that, see Dunlap &
Kowert, under review.). Design decisions have meaning and power, and in the words of Robin
Williams from Dead Poets Society, “No matter what anybody tells you, words and ideas can
change the world.”
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Table 1. Mental illness character tropes in video games
Trope Description Example from
traditional media
Example from
video games
Homicidal Maniac A person with an identifiable mental illness who is
dangerously violent and requires incarceration.
Norman Bates,
Psycho (1960)
Kefka Palazzo,
Final Fantasy VI
(1994)
Narcissistic Parasite
A person with an identifiable mental illness who is
self-obsessed and over concerned with their own
problems.
Chloe Allen,
Lovesick (1983)
Javik,
Mass Effect 3 (2012)
Female Patient as
Seductress
A female with an identifiable mental illness
portrayed as a seductress and/or nymphomaniac of
mythic proportions.
Kate Miller,
Dressed to Kill (1980)
Harley Quinn,
Batman: Arkham
Asylum (2009)
Rebellious Free Spirit
A person with an identifiable mental illness being
portrayed as egocentric, rude, obnoxious and
deceptive. Often dispenses homilies to others.
R. P. McMurphy, One
Flew Over the Cuckoo’s
Nest (1975)
Claptrap,
Borderlands (2009)
Specially Gifted/
Enlightened
A person with an identifiable mental illness who
possess special powers that are either related to the
mental illness or serve to compensate for the
disorder.
Raymond Babbitt,
Rain Man (1988)
Sandal,
Dragon Age (2009)
Zoo Specimen A person portrayed as dehumanized, without basic
rights, and as a creature to be observed and studied.
Virginia Cunningham,
Snake Pit (1948)
Sigma,
Overwatch (2016)
Simpleton
Often appearing in children’s cartoons or films, a
person who appears lost, doesn’t comprehend, or
behaves in illogical or humorous ways.
Dopey,
Snow White (1937)
No-Bark Noonan,
Fallout: New Vegas
(2010)
Failure or Victim A person who is unresponsive to treatment, generally Lisa Rowe, Girl, AWOL Marine, Halo:
with few skills or abilities resulting in an
unproductive member of society. Interrupted (1999) Combat Evolved
(2001)
Psycho Psychologist
A mental health professional who displays
criminally negligent behavior, such as lack of
empathy, callous frustration, or self-destructive
advice. Often has ulterior motives and actively abuse
the therapeutic relationship.
Hannibal Lecter, Silence
of the Lambs (1991)
Isiah Friedlander,
Grand Theft
Auto V (2013)
