> ## Documentation Index
> Fetch the complete documentation index at: https://devdocs.xbox.com/llms.txt
> Use this file to discover all available pages before exploring further.

# XAG 123: Mental health best practices

> Give players control over game content that may impact mental health, and represent characters with mental health conditions accurately and respectfully.

<Warning>
  **Content warning.** This guideline discusses topics commonly associated with traumatic events, phobias, and other potentially triggering content. The information is provided to help developers create safer, more inclusive experiences for all players.
</Warning>

## Goal

Ensure players are informed about in-game content that may negatively impact their mental health or well-being **before** they encounter it, and provide adequate customization to avoid, remove, or bypass that content. Achieve this through content warnings, customization options, and intentional efforts to avoid stereotyped or stigmatized portrayals of characters with mental health conditions.

## Overview

Per the [U.S. National Alliance on Mental Illness](https://nami.org/About-Mental-Illness/Mental-Health-Conditions), 1 in 5 American adults experiences mental illness each year. Common conditions include anxiety, personality disorders, depression, eating disorders, OCD, PTSD, psychosis, and schizophrenia.

Game narratives often mirror real experiences, but for some players, certain content elicits negative emotional, physical, or psychological responses. Depictions of common phobias, traumatic events, addictive substances or behaviors, and character portrayals of mental health conditions can pose serious barriers.

This XAG is **not** intended to encourage developers to remove such content — creators retain full creative autonomy. Instead, it raises awareness of content that may impact players with mental health conditions and offers solutions for more inclusive experiences.

<Note>
  Mental health fluctuates for all people. Intentional efforts here benefit every player, not just those with diagnosed conditions.
</Note>

## Scoping questions

Does your game include any of the following?

* Content that may elicit adverse responses: sources of common phobias; depictions of trauma (military combat, assault, domestic violence, violence against animals or children, loss of a loved one, discrimination, cults, oppressive governments); portrayal of addictive substances/behaviors (alcohol, drugs, simulated gambling).
* Depictions or interpretations of characters with mental health conditions.
* Depictions or allusions to self-harm, suicide, binge eating, purging, restricting food, or substance abuse.

## Background

### Barriers related to sensitive content

<CardGroup cols={2}>
  <Card title="Traumatic events" icon="heart-crack">
    PTSD can develop from experiencing or witnessing frightening, shocking, dangerous, or grief-inducing events. Unexpected exposure to related in-game content can trigger flashbacks, distressing thoughts, and physical stress responses — with lasting impact on the player's life.
  </Card>

  <Card title="Harmful actions or behaviors" icon="triangle-exclamation">
    Portrayals of suicide, self-harm, and similar behaviors can prompt imitative behavior, especially when depicted as quick, painless, or effective, when specific methods are shown, or when consequences appear positive. Avoid romanticization; keep methods vague; portray the reality of suffering.
  </Card>

  <Card title="Addictions" icon="pills">
    Players in recovery from substance or behavioral addictions may want to avoid content depicting alcohol, drugs, gambling environments, or risk-reward mechanics (e.g., paid loot boxes). Awareness before purchase is critical for these players.
  </Card>

  <Card title="Phobias" icon="spider">
    Arachnophobia, ophidiophobia, acrophobia, aerophobia, trypanophobia, aquaphobia, coulrophobia, trypophobia, and more. Unexpected visual exposure can cause intense physical and psychological reactions including panic attacks, nausea, and prolonged anxiety.
  </Card>
</CardGroup>

### Barriers related to character representation

One-dimensional or stigmatized portrayals of characters with mental health conditions can harm players with those conditions (via negative self-image and self-doubt) and reinforce inaccurate societal perceptions. Common stigmatizing patterns to avoid:

* Characters with psychiatric conditions portrayed as consistently unpredictable, extremely violent, or detached from reality.
* Reducing OCD to purely repetitive, ritualistic behavior.
* Infantilizing characters with learning or cognitive disabilities.
* Associating mental illness with villainy.

## Approaches to support players

<CardGroup cols={2}>
  <Card title="Pre-purchase documentation" icon="file-lines">
    Publish accessible, easy-to-find online documentation describing sensitive themes, subjects, and content — available before purchase.
  </Card>

  <Card title="In-game warnings" icon="bell">
    Show warnings at launch and, optionally, before individual missions, cutscenes, or dialogues that contain sensitive content.
  </Card>

  <Card title="Skip or bypass options" icon="forward">
    Let players skip cutscenes or missions with potentially harmful content — including mid-way through — without blocking storyline progression.
  </Card>

  <Card title="Content customization" icon="sliders">
    Allow players to alter the appearance or presence of triggering content (e.g., an arachnophobia mode, gore/profanity toggles).
  </Card>

  <Card title="Support resources" icon="life-ring">
    Provide locale-specific hotlines and websites in-game at any time — not only on launch screens or credits.
  </Card>

  <Card title="Collaborate with players" icon="users">
    Work directly with players who have the conditions being represented to ensure accuracy, respect, and effective warning/customization design.
  </Card>
</CardGroup>

## Key areas where mental health considerations matter

* Game launch screens
* Gameplay featuring upsetting content
* Full Motion Videos (FMVs)
* Mid-game cutscenes
* Character models and representation
* The game's script
* The game's product description page and trailers

## Implementation guidelines

<Note>
  The guidelines below apply to games containing content described in the scoping questions above.
</Note>

<Steps>
  <Step title="Publish detailed pre-purchase content descriptions">
    Provide detailed descriptions of content that may cause adverse emotional or psychological responses. Free online documentation must be reviewable **before** purchase and available in-game. Documentation itself must meet web accessibility standards.

    *Example:* *Tell Me Why* publishes a public [FAQ](https://www.tellmewhygame.com/faq/) describing the presence and context of transphobia, misgendering, and violence in the narrative so trans and queer players can make informed decisions.
  </Step>

  <Step title="Warn players at game launch">
    Display a mental health advisory when the game launches.

    *Example:* *Psychonauts 2* opens with an advisory that lists depicted conditions (addiction, PTSD, panic attacks, anxiety, delusions) plus phobia triggers (dentistry, tight spaces, vomit), and links to takethis.org resources. Players must press **B** — not the standard **A** — to advance, preventing accidental skip.

    *Example:* *Hellblade: Senua's Sacrifice* opens with a warning about representations of psychosis and links to HellBladeHelp.info.
  </Step>

  <Step title="Offer per-scene in-game warnings">
    Provide a setting that enables warnings before specific game areas, cutscenes, or dialogues that contain sensitive content.

    *Example:* *Ikenfell* has content warnings enabled by default (players can toggle) and shows event-specific text such as "self hate," "mention but no depiction of blood, horror," and "upcoming depiction of non-graphic deaths, traumatic recollection."
  </Step>

  <Step title="Provide content customization options">
    Where applicable, let players lessen or remove sensitive content — visual appearance of characters, gore, profanity, animal death, and similar.

    *Example:* *Grounded* offers an "Arachnophobia Safe Mode" that visually transforms spiders on a 1–5 scale without affecting gameplay or difficulty.

    *Example:* *Assassin's Creed Valhalla* lets players disable nudity, blood, dismemberment, and post-death assassination sequences.
  </Step>

  <Step title="Allow skipping challenging cutscenes or missions">
    Provide a skip/bypass option for cutscenes or missions dealing with particularly challenging content, including mid-scene.
  </Step>

  <Step title="Surface mental health resources in-game">
    Provide access to region-specific helplines and mental health resources from any point in the game — not only at launch or in credits.

    *Example:* *Hellblade* offers a country-selector support page with region-specific hotlines and screening tools. *Martha Is Dead* links to [Safe In Our World](https://safeinourworld.org/).
  </Step>

  <Step title="Make warnings and settings fully accessible">
    Content warnings and settings screens must meet other XAG guidelines that intersect — including [XAG 101: Text display](/build/game-principles/accessibility/xag-deep-dives/xag-101-text-display), [XAG 102: Contrast](/build/game-principles/accessibility/xag-deep-dives/xag-102-contrast), [XAG 106: Screen narration](/build/game-principles/accessibility/xag-deep-dives/xag-106-screen-narration), and [XAG 116: Time limits](/build/game-principles/accessibility/xag-deep-dives/xag-116-time-limits).
  </Step>

  <Step title="Represent characters accurately and respectfully">
    Avoid the following stigmatized patterns:

    * Characters with mental illness portrayed as consistently unpredictable, extremely violent, or void of reality.
    * Simplifying OCD to purely ritualistic behaviors.
    * Infantilizing characters with learning or cognitive disabilities.
    * Associating mental illness with villainy.

    Work with the disability community to ensure accurate, non-stigmatizing representation.
  </Step>
</Steps>

<Tip>
  Thank you to the Gaming and Disability Community, Ninja Theory, Dorian Stewart, Paul Fletcher, Lucie Daniel-Watanabe, the Safe in Our World team and its clinical advisory board, and all collaborators whose expertise shaped this guideline.
</Tip>

## Potential player impact

This XAG reduces barriers for:

* Players with mental health conditions
* Younger players
* Players who prefer to avoid certain types of content or topics

## Resources and tools

| Type    | Link                                                                                |
| ------- | ----------------------------------------------------------------------------------- |
| Website | [Take This](https://www.takethis.org/)                                              |
| Website | [Safe in Our World — Mental Health Charity for Gamers](https://safeinourworld.org/) |


## Related topics

- [XBOX Accessibility Guidelines (XAG)](/build/game-principles/accessibility/xbox-accessibility-guidelines.md)
- [Best practices](/services/xbox-services/develop/best-practices/index.md)
- [GDK accessibility overview](/build/game-principles/accessibility/accessibility-overview.md)
- [Insights Best Practices](/services/playfab/data-analytics/legacy/insights/best-practices.md)
- [Throttling best practices](/services/playfab/live-service-management/service-gateway/throttling/best-practices.md)