A couple of hours into playing Darkest Dungeon, I started to feel like a real ass: See, I really should’ve sent Fitzroy—a mace wielding, holy word shouting “Vestal”—to the hospital because she had a bad case of tetanus. Fitzroy wound up with that tetanus because, after spending the last thirty minutes heroically bashing cultists and stitching together the wounds of her allies, I’d ordered her to open up a rusty torture device. I did this because I thought there was a chance that there might be some treasure inside it.

Um. There wasn’t. There was just tetanus.

But instead of sending her to the hospital (well, “the sanitarium”), where she could get that tetanus treated, I gave her a pouch of coins and sent her to the bar. Now just wait a second, hear me out: It turns out that getting tetanus (and combatting the skeletal hordes) is really stressful. And since I wanted Fitzroy ready to face the dreaded Bone Necromancer, I needed to keep her stress in check. If I didn’t, then she could break down at the most inopportune moment. So, the bar it is. A little lockjaw can wait.

Darkest Dungeon is a tactical, party-based roguelike with a Lovecraftian flair. You play as the last heir of a fallen noble house. It’s your job to recruit and command a set of heroes, sending them into the decrepit bowels of a ruined estate—and the corrupt environs surrounding it. There’s a lot to like here. Darkest Dungeon’s aesthetic (including its use of a Bastion-style narrator) is stunning, and it contributes to the spring-like, tense-and-release feeling of the game’s turn based, positional combat. The adventuring slots nicely into a simple, yet fulfilling town-upgrade system, which itself fits together with a unique take on character advancement. And it all hinges on managing the stress of your heroes.

It would be easy to fumble an analysis of Darkest Dungeon’s “stress” mechanics. I could pretend that it’s wholly novel, ignoring the history of meters and charts that reflect the mental state of protagonists both digital and analog. Alternatively, I could act like this was just another “sanity meter,” one more simple interpretation of the Lovecraftian trope of “madness.” But Darkest Dungeon’s latticed systems of “stress,” “quirks,” “afflictions,” and treatment go beyond the conventional depiction of “madness.” The result is something critical and frightening.

It’s worth understanding the backdrop that Darkest Dungeon exists against. The sanity meter has been in games in some form or another for decades now, but I wouldn’t be surprised if Eternal Darkness was the game that jumped to mind at the mention of the phrase. Frankly, it’s a game I hope we can finally stop praising.

Okay, that might be harsh: the developers at Silicon Knights deserve credit for weaving together a non-linear, intercontinental story in a genre that had previously been content with haunted houses and small towns. Playing as Alexandra Roivas, you’re tasked with investigating a mansion filled with mysterious artifacts and occult books, each of which transports you into the life of another character in a millennia-spanning story of Old Gods, romance, and betrayal. But it’s the patented (no, really) sanity meter that made Eternal Darkness famous, and a decade of distance reveals it to be a lot less interesting (and a lot more problematic) than it may have first seemed.

Whenever Alexandra (or any of the other playable characters in Eternal Darkness) is seen by a monster, their sanity meter decreases. And as “the character’s sanity level decreases,” reads the patent, “game play is effected [sic] such as by controlling game effects, audio effects, creating hallucinations and the like.” There are dozens of these. As you step into a new room, you could hear a distant scream, or notice blood dripping down the walls. Some of these effects break the fourth wall, surprising you with a message congratulating you on completing the game’s demo, or tricking you by feigning an error screen. A moment or two later, regular gameplay continues.

These sanity effects are structurally more like pranks than interrogations of mental health. (And let’s be clear, Eternal Darkness takes itself very seriously in every other way.) They are not a smart interpolation of Lovecraftian convention, they’re a novelty. And like all novelties, once you understand how the system works, the sanity meter loses a lot of its allure.

Eternal Darkness is not alone, of course. If you can put up with the occasional bit of ableist language, check this list of media with sanity meters and you’ll see a lot of common design. Most of these meters have a single axis, with sanity on one side and insanity on the other. Maxing out the meter (that is, “going insane,”) tends to result in a predictably bad outcome: You lose control of your character, or get the bad ending, or die (either directly or indirectly). In many cases, the “sanity effect” is a single instance, not a long term condition, and rarely relevant to the specifics of the character or their experiences. The few games that do treat mental health as a long-term concern have other problems. Rogue Legacy, for instance, includes a number of psychological disorders in its genetic “traits” system, but these are played for laughs. If you choose a character with dementia, the trait description reads “You are insane!” Great.

Games like these present a deeply reductive view of mental health, which is a complicated and often unpredictable component of being. These sanity systems often feel tacked on and underdeveloped, which is a shame because my argument isn’t that we should totally avoid making games that address mental health. Instead, I believe that even within the constraints of the horror and fantasy genres, there’s a better way to tackle it.

I came to Lovecraftian horror in the best way possible. It was my first year of college and a close friend—someone I trusted—was upfront about all the benefits and the risks. This sounds like a joke, but I’m serious.

Lovecraft’s oeuvre—influential though it may be—is a minefield of racism and classism, and (unsurprisingly) his depiction of mental breaks are at once sensuous and sensationalist. So it was important that my guide through cosmic horror was willing to address these things, sometimes in ways I’m not even sure he realized he was doing.

Cosmic horror, he told me, was fascinating because it wasn’t just about what horrific, gory thing might happen to you. It was about realizing some terrible, uncanny truth that was there all along. You realized that something you assumed to be fundamentally true (and fundamentally important), was in fact a lie. “You know that scene in Apollo 13, where the engineers have to work out how to put the cube filter box into the cylindrical housing? Cosmic horror is about figuring out not only how to fit the square peg into the round hole, but realizing that it fit all along.” Lovecraft (and his influences and successors) shook things as fundamental as geometry and time.

But, oddly, that’s not how my friend handled cosmic horror. Whenever we sat around the table to play a session of Call of Cthulhu, Chaosium’s tabletop roleplaying game, the stories he wove reached not only out to the stars, but inwards, towards the personal, emotional, and cultural. Yes, the big climactic moments in these games dealt with seeing beyond the veil, learning that the world was a way that it couldn’t possibly be. But these moments were couched in and reflected smaller, more human concerns. These games featured self-doubting teens, under-paid academics, and women who felt constrained by their culturally mandated gender roles. When otherworldly terror came to bear, these anxieties came with it.

That he managed to do that was astounding, given the framework. Call of Cthulhu, like those other games, has a linear representation of sanity: It’s a statistic starting at 100 and dropping whenever a game rule says so. Gaze on the terrible visage of a fishman? Lose some sanity points, because that’s not how faces work. Learn a bit too much about how geometry isn’t? Lose some more points. If you lose a lot all at once, you might take a permanent psychological scar. Played strictly by the book, this system isn’t exactly handled with care. You roll some dice and look at a chart: “You read a really evil book? Cool, now you—rolls some dice—desperately want to eat lots and lots of sand.” It’s rough.

Thankfully, like many tabletop RPGs, the GM is able to wield personal fiat at the table. And my GM did so to great effect. So when my erstwhile-socialist-turned-Pinkerton was sent to the little mining town to make sure that the impoverished workers there weren’t shirking their duty to the company, he had to stare down more than just the local cult. And since he refused to face his own failings, it felt somehow right that my GM decided that he’d psychosomatically lost his vision after catching sight of the strange beast that lived in the caves. The metaphor was right on the nose, sure, but it was better than primarily treating psychiatric disorders as setting-appropriate debuffs.

It was more than just player “sanity” that received care and attention, it was also the broader conception of “madness” in Lovecraftian horror. What sets the leader of the local cult down his path? The horrors of industrialism, maybe. Or flip that: What unearths the ancient horror? Maybe the reach of colonial power, which uses the party as its heartless fingers. My GM realized that “madness” in stories like these reflected greater anxieties. This is, of course, not innately problem-free. After all, Lovecraft’s own stories reflected his anxieties about race (especially miscegenation), class, and religion.

It’s worth saying, of course, that mental health concerns are a material reality that actual humans have to deal with. Any fictional depiction should recognize that, instead of carelessly “leveraging” or “deploying” concepts like “insanity,” even as metaphor. But if you handle the topic critically and cautiously, as Darkest Dungeon manages to do, the result can be something special.

The differences between those old sanity meters and Darkest Dungeon’s depiction of mental health is substantial. Maybe that should be obvious, since Red Hook Games decided to avoid words like “sanity” altogether. Instead, your characters have a “stress meter,” a handful of “quirks,” and can develop “afflictions” and “heroic bonuses” through play.

Every adventurer starts with an empty stress meter and a few quirks, both positive and negative. These quirks represent a wide range of characteristics, from personal preferences to physical capabilities, from special knowledge to (yes) psychological diagnoses. But mental health isn’t treated as more or less important (or pathological) than other personal traits.

Fitzroy, for instance, began the game with the positive quirk “Natural Eye” (giving her a bonus to ranged attacks) and the negative quirks Thin Blooded (making her more susceptible to “blight” attacks) and Lygophobia (increasing the amount of stress she receives when in dim light.) These quirks make each character unique, not only in terms of their capabilities, but also vulnerabilities. Where other games with sanity systems treat every individual as equally sensitive to the same triggers, Darkest Dungeon recognizes that we all carry our own baggage. So, while everyone gets stressed when an undead warrior critically strikes them with an axe, Fitzroy takes it really poorly when that happens in the dark. On the other hand, Bolam the plague doctor has “Hater of Unholy,” so she takes less stress damage. She isn’t scared of the undead so much as furious at them.

This baggage (psychological or otherwise) doesn’t exist in a vacuum, either. Who we are can affect who we become and our relationships with those around us. As a character moves through the dungeon, the actions they take can raise and lower their stress level and lead them to develop new quirks (like getting tetanus, for instance). They’ll also receive these quirks after they return from a dungeon. More dramatically, while running out of “sanity points” in other games invariably leads to negative repercussions, in Darkest Dungeon things work differently. Adventurers with maxed out stress meters can either succumb to the pressure or heroically overcome it, developing short term characteristics that can change the entire dynamic of the adventure. It’s another classic trope, but at least it’s a more nuanced one than guaranteed “madness.”

Stress and quirks aren’t punchlines, either—they’re semi-permanent. The Sanitarium is an all-purpose hospital, which removes quirks with time and money. To reduce their stress, heroes need to be sent to the tavern or the abbey. Quirks can limit them there, too. There are some things in life that make praying difficult.

I don’t think that Darkest Dungeon is faultless, but it is steps beyond other, similar games. And as I played more and more, I realized that there was a quiet (and maybe unintentional) critique implicit in its depiction of mental health.

A couple of hours in, I’d realized that while combat and exploration are Darkest Dungeon’s most obvious challenges, they aren’t its hardest. A player who learns only how to kill enemies isn’t going to do as well as the player who understands how to manage character stress, build teams with complementary quirks, and anticipate potential problems. You need to decide who gets treatment, and when. Said plainly, good Darkest Dungeon players are good middle managers. Or (since this is Lovecraftian horror, after all) good villains. If this were a game of Call of Cthulhu, you’d be the antagonist—the fallen aristocrat so thirsty to recover his family’s power that he sacrifices the lives of dozens to unearth terrible, terrible things.

After you pay to recruit these workers they sit in your roster, presumably having their basic needs met but little else. They can’t access the abbey or the tavern to reduce their stress unless you explicitly pay for them to. And you hire these poor souls on what must be a life contract: No one gets to quit, even as they beg you not to send them back into those haunted woods.

That isn’t an embellishment, either. There are little things that animate these people, things that we don’t traditionally think of as “game systems.” As you maneuver through the menus or direct your heroes through the dungeons, they’ll occasionally voice their opinions in little text bubbles. And sometimes they say, plainly, that they don’t want to go on a mission right now: “Please don’t send me back!” But you send them anyway. They vocalize their falls from faith, and you push them harder. You ignore them, and look at the stat screen instead, ignoring them as their comments literally appear on top of that window. “Not another expedition—Anything but that!” Fitzroy says. But you only see that she got the quirk “Ruins Tactician” on that last mission. “That gives her a bonus to damage in the Ruins,” you’ll say, “And the Bone Necromancer is in the ruins! Cool!” Cool.

And then she and her team are in the halls of the wrecked estate. You let their torch run low (even though that means they’ll take more stress damage) because a low torchlight means finding more loot. And then you’ll have her reach into that rusty iron maiden, again. Hey, she already has tetanus, right? And her stress level hits max, but oh, wow, she pushes through it and gains the “Courageous” Heroic Bonus, which lets her keep the team’s stress in check for the rest of the mission. And they do it: The dreaded necromancer is slain.

But. Oh.

Hrm.

Fitzroy sure has a lot of red on her quirk list now, doesn’t she?

She still has the lygophobia and thin blood that she started with. Plus tetanus and claustrophobia from the second time you (that is, I) made her go into that iron maiden. And she has a “Guilty Conscience.” The mouseover text says that she “bears the crushing guilt of deeds real and imagined.” I slide the mouse cursor over this long list of red words and sigh. “I don’t even know if ‘Guilty Conscience’ has a real effect,” I say, “but it sounds bad.”

The critique Darkest Dungeon is making is of critique of me, and of the culture that taught me to read words like “crushing guilt” and wonder if it has a “real” effect on a person.

But I don’t see that critique, not yet. Right now all I see is that it’s going to cost me a whole lot of time and money to get Fitzroy back into fighting condition. Plus, there’s a new Vestal on the list of potential recruits, and she has some great quirks. I mean listen, what was I gonna do, just let Fitzroy take up a slot in my limited roster while I’m waiting around for her to recover? I’m trying to explore a dungeon, here. Some things are just business realities.

Fitzroy couldn’t quit when she wanted to. That was literally not an option for her. I sent her back into battle, and now that she’s come out wounded physically, emotionally, and psychologically I’m cutting her loose. Like the game says, I’m casting her aside like a burnt torch.

I wrote above that the best horror stories do more than just scare us with gore or violence, they make manifest a deeper anxiety. Something cultural or social. If there is an anxiety being reflected by Darkest Dungeon, it’s this: We live in a world that is willing to ruin people for a little net gain.

The last decade has taught us this again and again. Soldiers, many recruited from low-income families, return home only to find medical support lacking. Victims of exploitative loans watch as big business is bailed out, and they’re left to tread water. “Content producers” beg platform holders for better protection from harassment, but receive little to none. Marginalized communities struggle through systemic oppression only to receive lectures from outsiders on how they are to be blamed for all of their problems. It can feel like (and it may be the case that) this is a world that doesn’t have the infrastructure to help these people, nor the desire to build it.

And there is a second, deeper anxiety, too. A more personal one. Darkest Dungeon makes us confront the idea that we are complicit in these systems, or that we’re even willing to contribute to them ourselves. In fact, we do it on a daily basis, leaning on digital tools to do the work of reduction for us. With a right click and a mouseover, we can see an “employee history” and lose sight of the employee herself. We scan Twitter feeds and user timelines to draw rash conclusions about the complete character of those we observe. We’re eager to turn everyone (and everything they do) into data: usable, reliable, replaceable.

A few hours after firing Fitzroy I find myself wondering where she is. I find myself wondering where all of the adventurers I’d fired are. What would a world like this offer people like them? And I wonder if the game saves their data, or if it’s erased the second I hit that red X under their names.

The moment passes. I send another group into the ruins. I buy them some extra bandages this time. It’s the least I could do.

Austin Walker is a PhD Candidate in Media Studies at the University of Western Ontario, writing about games, labor and culture. He writes about games at @austin_walker and at Clockwork Worlds.