Madness, Control and Agency in Video Games

Researcher Rebecca Milton explores the unique ability of interactive video games to represent experiences of Madness.

A great deal of thinking has been done about how Madness is represented in media, what examples are given, and how they perpetuate or dismantle stereotypes of Madness. But when looking at media forms that are interactive in nature, like video games, things become very different. No longer are we simply an observer – we become a participant, a part of the world being constructed through our chosen media. We gain agency within the given world, and this agency is controlled by the story, by the interactive form, and when it comes to Madness, by the very way in which that Madness is portrayed.

The powerful relationship between interactivity and Madness is why I have chosen to focus on interactive media in my PhD. In the medical and health humanities, any previous work on Madness in video games has often focused on the therapeutic use of video games. In looking at how the embodied experience of Madness is transmitted, I find myself walking on relatively untrod ground – and yet, there is much to be found therein.

Memory and Identity in Pillars of Eternity

Pillars of Eternity (Obsidian Entertainment, 2015)[1] is a Role Playing Game (RPG) in the style of the Baldur’s Gate series, set in the fantasy world of Eora, where Gods and mortals vie for power over death itself. In the game the player character experiences a life-changing magical event that awakens memories of a past life, the story of which becomes the focus of the game. They are warned that this awakening will likely drive them to insanity. The player gains many more memories throughout the game. These are shown as written cut-scenes – sometimes with options for the player to reply, and sometimes not. They also see visual representations of these memories in vivid purple-blue apparitions that appear when navigating the map (Fig. 1).

Fig. 1. A still from the game Pillars of Eternity

Over and over again, the character is warned that their newly gained power will surely drive them to madness. But it does not. In fact, the character retains not only their own agency, but through the climaxes of both Pillars and its sequel, power over countless souls and the reincarnation cycle itself. Though they continue to experience visions of their own past lives and the past lives of others, the player stays in control of their story. Whilst there is a mechanic whereby the player may find themselves unable to accept certain dialogue options, these restrictions are usually due to the character not having the right background or attribute. This is a common mechanic in games of this type, and is not utilised in the game as a way of representing the Mad experience.

Fig. 2. A still from the game Pillars of Eternity

In this sense then, the interactive nature of Pillars of Eternity is wasted on its Mad experience. The interactive nature of the game functions not just through what way the player chooses to go, but through these important choices that are made in dialogue trees, as shown above (Fig. 2). What could have been a much more immersive reflection on the experience of those with conditions such as dissociative identity disorder and schizophrenia, instead becomes much more like a typical book or film – an experience of Madness that is observed and represented, rather than felt or experienced.

Suicide and Choice in Please Knock on My Door

In comparison, the game Please Knock on My Door (Levall Games AB, 2017)[2] has a very different relationship with agency, control, and Madness. Interestingly, the game’s description is “a story-driven game which gives you control over a person suffering from depression and social anxiety” – a phrase which is not untrue, but also proven wrong in some respects by the game’s potential outcomes.

Fig. 3. A still from the game Please Knock on My Door.

In Please Knock, you find yourself in a top-down view of an apartment (Fig. 3). You have the ability to choose what actions you take, and to move the character around the apartment. You click to interact even with the textual inner narrative, moving it on as it appears. The passing of time is shown in weather and light from the window, and in timestamps as you undertake activities. Over time, the character’s inner thoughts become increasingly painful and vicious. They begin to appear not in white text, as they have done for the first half of the game, but in red. When picking activities such as whether or not to shower, some options begin to be greyed out and inaccessible – displaying the possibility of a choice which the player is not able to select. Even as it is presented, the choice is removed.

In my own playthrough, I went to prepare the character for another day of work, and instead found myself presented with the option to smash things in the apartment. Moving through the bathroom, where I had previously had the character shower for the day, I was instead given only one option: overdose (Fig. 4). This was shown in red text, with the screen swaying, and a blur appearing over the top-down view. “You deserve it…We deserve it…I…deserve it,” the red text reads. “I don’t want to feel like this anymore. It’s exhausting. Please. Make this pain stop. I’m begging you.” When playing, I waited. I watched the red text go through this and refused to press the one option given to me. Then, miraculously, there was a knock on the apartment door. I ran to it, freed from what to me was an all-too-familiar reality of death being the only option.

Fig. 4. A still from the game Please Knock on My Door.

In contrast to Pillars of Eternity, Please Knock plays with the giving and taking of that control. A method of interacting with the world is established, then removed, then given back, but in stuttering motions that incite frantic hammering of the keyboard. If Pillars was a passive form of Madness, Please Knock makes it active. In How Games Move Us, Katherine Isbister speaks of how games are unique in their ability to make us feel guilt (Isbister 2017). The bright red option to overdose filled me with a very similar shame and guilt to that which I remember feeling around the time of my own suicide attempts. That sense of wanting to do; wanting not to do; being able to do; not being able to do.

Video games are unique in their ability to portray that. There is much more to be said on this, too – when you consider the way saving and loading games, or checkpoints, interact with agency, it gets even more muddied and interesting. Is it truly removing the player’s agency if they can just reload an earlier save? “Ironman” modes that prohibit reloading play with such a thing, as do games where this sort of reloading is impossible.  In some games, choices made earlier on impact later events – such as in the game Life is Strange, where the player character’s ability to prevent another character’s suicide is based partly on whether they have interacted with that character before. And this is, of course, only to use the ultimate example of agency – the question of whether to live or die.

This ludic and narrative power is the reason I have chosen to focus part of my PhD thesis on video games when thinking about Madness in interactive media. There is so much that video games can do in terms of technology, with both video and audio at their disposal, as well as narrative and mechanical conventions to play with, in the constant mediation of the player’s agency. This power creates a unique affective experience that, in my opinion, deserves a lot more attention for its ability to help people understand – at least in part – what it feels like to be Mad.

Rebecca Milton is a PhD Candidate at the University of Kent, where she is working on embodied Madness in interactive media. She is a disabled, Autistic researcher who works at the intersection of Mad Studies, Disability Studies, and the Medical and Health Humanities. She can be found @melodioustear on Twitter, Twitch and TikTok.


Isbister, Katherine. 2017. How Games Move Us: Emotion by Design. Cambridge, Massachusetts: The MIT Press.

Recommended Further Reading

Ferchaud, Arienne, Jonmichael Seibert, Nicholas Sellers, and Nivia Escobar Salazar. 2020. ‘Reducing Mental Health Stigma Through Identification With Video Game Avatars With Mental Illness’. Frontiers in Psychology 11.

Papale, Luca. 2014. ‘Beyond Identification: Defining the Relationships Between Player and Avatar’. Journal of Games Criticism 1 (2).

Shapiro, Samuel, and Merrill Rotter. 2016. ‘Graphic Depictions: Portrayals of Mental Illness in Video Games’. Journal of Forensic Sciences 61 (6): 1592–95.

[1] Obsidian Entertainment. Pillars of Eternity. Xbox Game Studios. PC/Mac. 2015.

[2] Levall Games AB. Please Knock on My Door. Levall Games AB. PC. 2017.

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