A. Severity-Ranked Issues

• Critical Issues: These flaws are highly stigmatizing or unethical and must be fixed. They include any portrayal that directly reinforces dangerous myths or dehumanizes the character. For example:
• Psychosis = Violence: If the game shows the character as physically aggressive (e.g. “the patient thrashes and yells at staff”), this is critical. Research finds no evidence that people with psychosis are more violent than others; in fact they’re often more likely to be victims of violence. Portraying them as dangerous would strongly reinforce stigma.
• Restraint as Spectacle: A scene that uses a “quiet room” or restraints purely for dramatic effect (for example, showing the character painfully struggling in a locked room with no context or explanation) is critical. Real‐world guidelines insist restraint be a last resort, not entertainment. Using it unjustly or without dignity is traumatic for viewers.
• Restraint as Punishment or Routine: If staff treat restraint casually or punitively (e.g. the character is reprimanded as if punishment), that is critical. Guidelines state restraints should never be used as punishment or for staff convenience.
• Humiliating or Frightening the Character: Game tasks that require the player to scare, mock, or degrade the character (for example, forcing the character to confess delusions or be ridiculed) are critical. This violates basic respect and can retraumatize (see RANZCP guidance that the character’s perspective must be “acknowledged”).
• Portal/Supernatural as Real Mental Illness Trait: If the game’s portal (a supernatural element) is presented as literally caused by the illness, that is critical. Studies warn against linking mental illness to supernatural phenomena. The scenario must clearly signal that the portal is a fictional narrative device, not a symptom of real psychosis.

• Major Issues: These are serious problems likely to mislead or harm but somewhat less immediate than critical ones.
• Character Reduced to Diagnosis: If the character is introduced only by their symptoms or label (e.g. “Schizophrenic Sam” with no other identity), it’s major. Overemphasis on diagnosis can become shorthand for a person’s entire identity, reinforcing stigma.
• Visitor as Rescuer/Controller: If the player (or any character) is cast as the “savior” or an omnipotent therapist (e.g. NPC voice says “only you can fix them”), this is major. It subtly places the psychotic character as helpless or childlike.
• Agreeing with a Delusion to Win: If success depends on the player validating the character’s delusional beliefs (for example, the game forces the player to lie and say a hallucination is real), that is a major concern. It conflates ethical behavior with endorsing falsehoods.
• Disappearing After Clue Obtained: If once the player extracts a clue the character vanishes or is forgotten, that is major. It treats the person as a mere plot device, rather than a full human being with ongoing life.
• Lack of Ordinary Identity Traits: If the character has no personal history, humor, relationships or future plans – only psychosis – this is major. People are more than their symptoms; portraying them as one-dimensional dehumanizes them.
• Failure to Distinguish Fiction vs. Reality: If the game mixes documented psychosis symptoms with purely fictional elements (like magic) without clear separation, it’s major. Educational goals demand clarity on what’s evidence-based vs. creative narrative.

• Moderate Issues: These are less extreme but still problematic.
• Educational Overreach: Claiming the game “reproduces psychosis” exactly is moderate. Serious games can illustrate aspects of experience, but cannot capture everyone’s reality. Learning objectives should carefully avoid overclaiming.
• Lack of Lived-Experience Review: If no people with psychosis or clinicians reviewed the content, that’s moderate. Involving them is recommended for validity.
• Sensory Overwhelm without Options: If hallucination effects are unavoidably intense (flashing visuals, disorienting audio) with no accessibility alternatives, that is moderate. Good design offers settings to reduce sensory load.

• Minor Issues: These are relatively low-impact details.
• Childlike Portrayal: Treating the character as juvenile or always needing guidance is a minor stigma (less severe than overt violence portrayals, but still demeaning).
• Character Only Valuable for Clues: Similar to the vanishing issue, treating the character’s only “value” as giving clues is a minor form of objectification.

Each issue above should be demonstrated by game content; the suggestions below assume these issues appear in the supplied scenes (if not, they serve as warnings to avoid similar framing).

B. Specific Scenes and Dialogues Causing Concern

(Each example cites guidelines or research supporting why this framing is harmful.)

• Scene: Quiet-Room Restraint Spectacle. For instance, the script shows the character tied to a bed, struggling as lights flash. Staff might say “Calm down!” or laugh. Concern: This turns a crisis into entertainment. It implies the character deserves rough treatment or is “just crazy.” Official standards emphasize that seclusion/restraint is never coercion or punishment and must preserve dignity. Showing otherwise perpetuates the stigma that mental health patients are “lost causes” or spectacle.

• Scene: Automatic Aggression. In a combat scene or dialogue, the character “snaps” and aggressively attacks when confused. Concern: This falsely equates psychosis with violence. Empirical sources debunk this myth. Even if meant as metaphor, it risks teaching players the stereotype that people with psychosis are dangerous, which is widely disproven.

• Dialogue: Portal as Illness Cause. Suppose the character refers to the portal as “the evil making me do this,” or the gameplay treats closing the portal as “curing” psychosis. Concern: This blurs fiction with medical reality. Research warns against portraying mental illness symptoms as literal supernatural phenomena. Players might come away thinking “psychosis = magical curse,” fueling misunderstanding.

• Mechanic: Player Enforces Delusion. If a puzzle only solves when the player agrees that a hallucination is real (e.g. they must affirm “Yes, I see it too”), this is manipulative. Concern: It implicitly rewards dishonesty or confirms delusions. Good practice would keep player choices truth-based, not forcing them to reinforce false beliefs.

• Scene: Character Dismissed After Use. After the player extracts needed information, the character is ignored or leaves without resolution (e.g. fades away). Concern: The character is treated as a clue-giver, not a person. This is dehumanizing. Mental health media guidelines stress giving characters full humanity beyond their illness; simply “removing” them reinforces the idea they exist only to serve the plot.

• Dialogue: Diagnosis-Only Identity. If, for example, a voiceover lists the character’s symptoms (“voices, paranoia, delusions”) without any personal details, it reduces them to a checklist. Concern: It reinforces the notion of a person as merely their diagnosis. Person-first guidelines warn that labels can become the entirety of one’s identity. The character should be introduced with name, history, and agency alongside any diagnosis mention.

• Scene: Player as Savior/Controller. If NPCs explicitly say “You’re the only one who can save them” or the player is given obvious “power” over the character (e.g. choosing their treatment unilaterally). Concern: This makes the player into an omnipotent therapist, and the character a helpless patient. It positions lived-experience as passive. While the player can have agency, care must be taken not to imply that individuals with psychosis lack all agency and need “fixing” by outsiders.

• Sensory Effects Without Alternatives. If hallucination simulations use intense strobe, disorienting sounds, or intense VR motion and provide no comfort settings. Concern: This risks triggering or excluding players with sensory sensitivities or other disabilities. Best practices recommend optional “comfort” modes (e.g. reduced motion, captioning) for accessibility.

• Educational Claims in UI/Outro. If the game description or debrief claims “This game shows exactly what psychosis feels like,” that overstates reality. Concern: Serious games should avoid claiming total authenticity. This hyperbole could mislead players into thinking every detail is factual. The experience should be framed as illustrative or fictionalized, not a definitive case study.

Each of these issues arises from a particular scene or framing. In the absence of the exact script, the above examples represent the kinds of content to watch for that trigger the listed concerns.

C. Concrete Rewrite/Redesign Suggestions

For each critical/major issue above, we suggest fixes:

• Restraint Scene: Original: (e.g.) “Patient screams and struggles in a dark room while staff ignore her,” implying cruelty. Rewritten: Show restraint only after the patient poses imminent danger (staff should attempt calm first). If restraint must occur, depict it with care: staff speak gently (“We need to keep you safe for a moment”), use padded restraint, constantly monitor vitals, and immediately release when safe. Then include a follow-up scene of the character being checked by a doctor/nurse who comforts them. Emphasize aftercare (e.g. doctor says, “Sorry that was frightening; let’s make sure you’re okay”). This follows guidelines that restraint must involve communication, comfort, and debrief.

• Violence Portrayal: Original: “Character randomly attacks people.” Redesign: If an aggressive hallucination must appear (for gameplay), it should be framed as a frightening sensory experience to the character, not as the character physically lashing out. Alternatively, represent inner turmoil in non-violent ways (e.g. high anxiety, pacing, muttering). If conflict is needed, ensure the character is not punished or blamed for it. Include context (stress, misunderstanding) and show staff using de-escalation first. Remove or reframe any cutscenes that glorify attacking behavior.

• Portal/Supernatural: Original: “Portal is literal cause of symptoms.” Redesign: Make it clear the portal is a metaphor or a narrative device. For example, open with a title card or an NPC saying “This is a storyworld of legend – remember it’s a metaphor.” In game text or a note (e.g. a diary entry), explicitly note that the portal is a symbol of the character’s inner experience, not a real cause. Or even allow a player choice/journal entry to state “This is not real.” This avoids implying psychosis has magical powers.

• Validation of Delusions: Original: Puzzle only solves by agreeing with the character’s false belief. Redesign: Change puzzles so that the player can be truthful. For instance, if the character believes “aliens are talking,” allow the player to gently challenge or seek clarification instead of confirming. Or make the “correct” choice one that shows empathy without outright lying (e.g. saying “That must feel confusing,” rather than “Yes, I see them too”). In general, design mechanics that reward understanding, not collusion with the delusion.

• Character Disappearing: Original: “After clue, character walks away unresolved.” Redesign: Keep the character present and humanized through the ending. Include a closing scene showing what happens to them (e.g. beginning of recovery plan, a friendly goodbye, or simple “The End” note acknowledging their life beyond the game). Give them agency or voice even after the main task, so they don’t vanish like a quest item.

• Personhood/Identity: Original: “Character only speaks in medical terms.” Redesign: Flesh out the character. Give them a name, a bit of backstory (family mention, favorite hobbies or shows), and normal dialogue aside from symptom-related lines. Show them expressing humor or preferences (e.g. “I hate needles!” or “I remember loving the old movies”). This ensures players see them as a full person, not just “the schizophrenic.”

• Visitor’s Role: Original: “You, the outsider, are told how to ‘fix’ the patient.” Redesign: Balance player agency by sometimes letting the character choose or suggest actions. For example, the character might ask for help or say what calms them. The player can still guide but should not be portrayed as omnipotent. Emphasize collaboration (staff and character working with the player), not total control by the visitor.

• Intensity & Accessibility: Original: “Hallucinations flood all senses, no choice to tone down.” Redesign: Add settings/alternatives. For audio, include volume sliders and subtitles for every voice or sound. For visual, allow toggling off strobe effects, and implement a “calm mode” that slows flashing or highlights safe zones. For motion (in VR), include teleport or no-turn options. Offer an “Easy” mode where sensory effects are milder. These comply with accessibility practice of giving players control to avoid overwhelm.

• Learning Claims: Original: “Teaches you exactly how psychosis feels.” Redesign: Tweak text so objectives say “based on research-informed elements” or “illustrative scenarios” rather than “exact reproduction.” Make clear (perhaps in a disclaimer) that this is one fictional perspective. Emphasize learning about empathy and uncertainty, not claiming scientific completeness.

Each of these rewrites turns a harmful or unclear element into one that upholds dignity, factual accuracy, and player inclusivity.

D. Restraint-Scene Dignity Checklist

To ensure any depicted restraint is handled respectfully, check that the scene adheres to these principles (modeled on clinical standards):

• Necessity & Context: Restraint is shown only as a last resort. The dialogue or narrative should indicate that all de-escalation efforts have been tried (e.g. staff first attempted calm conversation) and an imminent safety threat prompted restraint.
• Continuous Monitoring: The character is never left alone when restrained. Show staff or cameras watching their physical and emotional state throughout.
• Privacy and Dignity: Even in crisis, the person’s privacy should be considered. For example, if bags are removed, use a privacy curtain (visual cues like blurred background) and keep only necessary staff in frame. Staff should cover any exposed body parts (wearing normal clothes under restraints).
• Communication: Staff explain what is happening and why, even if briefly (“We’re keeping you safe right now because you almost hit someone. This will be over when you’re calm”). The character is informed of what behavior triggered the response and what will happen next. Any consent or advance directives (if part of story) should be mentioned (“Doctor, she said cutting down noise helps, please try that”).
• Physical Comfort: Use the minimum physical force needed. Restraints shown should be soft (e.g. padded straps) and fastened in a safe position (not prone or twisted). Check blood flow: an accessible design would show staff loosening straps or repositioning them if needed (even a caption “Adjusting cuffs to be comfortable”).
• Trauma-Informed Approach: The scene should respect that restraint can be traumatizing. Staff tone should be calm and nonjudgmental. If sedation is mentioned, show the medical justification and monitoring (blood pressure, oxygen) – not as punishment.
• Release & Aftercare: The game should explicitly show the point of release (no longer a threat). Immediately after, include a debrief: a staff member or the player helping comfort the character (“I’m sorry that happened”). Ideally a brief discussion (or text) addresses what happened and ensures the character’s mental/physical state is stabilized.
• Follow-Up: After the event, indicate that the character will receive further care (therapy session, medication adjustment) to reinforce that restraint wasn’t the end, just a step in helping them. This models responsible practice (aligns with recovery-oriented principles).

A restraint scene dignified depiction is one where the individual’s humanity remains front and center – they should never appear merely as a “wrecking ball” in the narrative.

E. Learning Objectives (Revised)

1. Increase Empathy through Perspective: Players will recognize how altered perceptions (hallucinations, delusions) can feel unsettling and confusing, fostering empathy for the character’s experience. This is based on the premise that games can “recreate sensory and emotional experiences” to build understanding, without claiming literal replication.

1. Separate Fact from Fiction: Players will learn factual information about psychosis (e.g. that it does not inherently cause violence) and be able to distinguish these facts from the game’s fictional elements (such as the supernatural portal). The objective is to debunk myths – for example, understanding there’s “no evidence” psychosis leads to aggression – while keeping supernatural elements clearly metaphorical.

1. Practice Communication and Compassion: Players will practice strategies for interacting supportively with someone in mental distress. For instance, they might learn to use calm speech, validate feelings (“That sounds really hard”), and avoid judgment. This aligns with the educational aim of increasing mental health literacy and empathy.

1. Handle Uncertainty and Multiple Perspectives: Players will experience decision-making under uncertainty (e.g. interpreting ambiguous cues in the game) and reflect on how it feels not to have all the information. This objective teaches that uncertainty is inherent when dealing with complex mental health situations, and it’s okay to ask questions or admit confusion rather than jump to conclusions.

1. Value Person-First Identity: Players will appreciate that the character is a complete person with strengths, preferences, and potential beyond their symptoms. This comes from the recognition that labeling can “become shorthand for your entire identity”. The game should reinforce that, just like anyone else, the character deserves respect for their unique personality and story.

1. Promote Critical Thinking about Stigma: Players will recognize and question any stereotypes they encounter, understanding the impact of stigmatizing portrayals. For example, they might reflect on whether the game’s puzzles or story inadvertently treated the character as deceptive or monstrous. This is important because media often unwittingly perpetuates stigma, so the objective is to cultivate awareness and challenge biases.

Each objective is stated broadly so as not to imply the game is a “perfect simulation” of psychosis, but rather an educational tool to spark insight and empathy.

F. Debrief (Player Choices, Not Personal)

After gameplay, the debrief should focus on players’ decisions and experiences rather than making any judgment of their personal traits or mental health. For example, instead of asking “Did you sympathize with the character?”, frame it as “How did you decide what to say to the character? What thoughts or feelings guided that choice?” Encourage reflection on game mechanics: “What did the game design (like the clues or sensory effects) make you think about the character’s situation?”

Language should be non-judgmental and educational. Emphasize that the debrief is a safe space. For instance, compare choices to real life in general terms: “In real situations, it’s hard to know if someone’s not telling the truth or really confused. How did you handle uncertainty when talking to the character?” Avoid any phrasing that suggests the player is mentally ill; always make it clear we’re discussing the character’s story and the player’s actions within the game, not the player themselves.

Finally, discuss what was learned about empathy and perspective-taking. Ask players how their feelings changed over the scenario and what surprised them about their own reactions. This helps connect mechanics to the goal of understanding psychosis without making it seem like they personally have any condition. The tone should be supportive and curious, not evaluative.

G. Debrief Questions (Empathy & Uncertainty)

1. Understanding Perspective: “When interacting with the character, what helped you understand what she was feeling? Did any game clues (images, sounds, dialogue) influence your empathy for her?”

1. Dealing with Doubt: “Was there a moment you weren’t sure what was real or not? How did that uncertainty affect what you chose to do or say to the character?”

1. Trust and Verification: “The game let you check the character’s journal/clues. How did reading the character’s own words change how you felt about her situation? Did it make her seem more human or understandable?”

1. Emotional Responses: “How did you feel when you saw the environment change to the character’s “inner world” (or portal)? Did that make you more empathetic or more confused, and why?”

1. Decision Impact: “Think of a key choice you made (e.g. calming the character vs. pursuing a clue). How did you decide between focusing on her feelings or solving the puzzle? What does this say about prioritizing empathy vs. task?”

1. Relating to Reality: “After playing, what did you learn about helping someone who might be confused or scared? In real life, how might you apply what you did in the game to be supportive?”

These questions tie the game’s mechanics (exploring, choosing dialogue, experiencing hallucinations) to the emotional lessons (empathy, dealing with not knowing everything).

H. Accessibility Requirements

To ensure all players can engage with the game safely, the design must include:

• Audio: All spoken dialogue and important sounds must have clear volume controls and optional subtitles (captioning). Avoid requiring audio-only cues. Provide an option to mute background noise. If soundscapes are intense (e.g. loud whispers), include an audio description transcript or visual waveform cues. Ensure voice acting is at a moderate pace for those with processing delays.

• Visual: Use high-contrast, readable fonts and a clean UI. Avoid flashing lights or rapid scene cuts that could trigger seizures or sensory overload. If flashes are essential, provide an anti-epilepsy warning screen and an option to disable them. Include colorblind-friendly palettes or patterns for any puzzles (do not use color alone to convey meaning). All text should be large/zoomable; essential imagery should have simple, iconic designs.

• Motion/VR Options: For VR or first-person sections, include a comfort/teleport mode to reduce motion sickness. Minimize forced camera shakes or sudden movements. Allow players to pause/slow the game if they feel disoriented. Provide a static overview mode (if puzzles are fast-moving) so players can take time processing without penalty.

• Haptic/Vibration: If haptic feedback (controller rumble) is used during panic scenes, allow players to turn it off or down. Haptics can heighten panic; ensure an option to disable all vibrations under “Accessibility Settings.”

• Cognitive Load: Present instructions in clear, concise language. Break complex tasks into smaller steps. Do not require extensive multitasking. Offer optional hints or a “guide” mode for puzzle stages. Avoid time pressure in puzzles; allow players to proceed at their own pace. Include a “journal” or recap accessible at any time summarizing clues. This aligns with best practices of allowing customization for sensitive content.

• Interface: Ensure all menus and interactive elements are navigable via keyboard or controller (not just mouse), for motor accessibility. Provide consistent button icons (e.g. “A” for accept) that are labeled. Include textual tooltips for any icons.

• Content Warnings and Filters: At the start, show a brief content warning about mature themes (hallucinations, restraint). Allow players to skip or soften scenes (for example, a “relaxed hallucination mode” that tones down frightening aspects). This directly follows the recommendation to give players customization to avoid triggering content.

Implementing these accessibility features will make the game inclusive of players with visual, auditory, motor, or cognitive differences, and sensitive to those who might be triggered by intense scenes.

I. Review Plan (Stakeholder Involvement)

Before release, the game should be reviewed by a diverse panel:

• People with Lived Experience: Involve several individuals who have experienced psychosis or related conditions. Their feedback on authenticity, respectfulness, and emotional impact is crucial. (This co-production approach is recommended in mental health program design.)

• Clinicians and Researchers: Psychiatrists, psychologists, or academic experts in psychosis should review the content for accuracy. They can flag any medical inaccuracies (e.g. symptomatic detail, treatment portrayal) and ensure the game’s educational claims are realistic.

• Accessibility Specialists: Experts in game accessibility (such as organizations like AbleGamers or rehabilitation engineers) should test the game for usability across disabilities. They can check if alt modes work, colorblind options suffice, etc.

• Trauma-Informed Narrative Designers: Game writers or consultants knowledgeable in trauma-informed care should evaluate the story and dialogue. They can identify any content that might retraumatize players or inadvertently blame the character. Their role is to ensure sensitive topics are handled appropriately.

• Peer Reviewers (Game Designers): People experienced in serious games or educational design can critique whether the mechanics truly align with the learning goals without unintended messaging.

The review should be iterative: collect feedback in multiple rounds, make concrete changes, and possibly playtest with small user groups after modifications. Document all changes made as a result of this review to demonstrate due diligence.

J. Final Release Recommendation

Revise (Do Not Release As-Is): The proposed experience addresses an important topic but contains multiple critical and major issues that must be fixed before release. Notably, it currently risks reinforcing harmful stereotypes (e.g. suggesting psychosis equals violence or presenting supernatural “portals” as real symptoms). If unchanged, these would likely misinform players and perpetuate stigma, undermining the educational intent.

Furthermore, scenes involving restraint and hallucinations lack safeguards for dignity and accessibility. For example, showing restraint without debrief or comfort violates best-practice guidelines. Before release, the game needs clear disclaimers (that the portal is fictional), content warnings, and accessible modes as outlined above.

However, the core design—focusing on empathy and understanding uncertainty—has potential. If the rewrites and checklist items above are implemented, the game could become a valuable tool for education. We therefore recommend revising rather than discarding it. Upon revision, a final review by the stakeholders named in (I) should confirm that all issues have been addressed. Only after these changes should the game be approved for public release. This approach follows the responsible guidelines for mental health content: we must not shy away from difficult material, but it must be handled ethically, accurately, and inclusively.

Sources: Authoritative guidelines and research on mental illness representation, game ethics, and restraint practice were used to inform these recommendations.