The Suffering: Ties That Bind follows in the footsteps of its predecessor by combining a disturbing horror atmosphere with action/shooter gameplay. Players can switch between third person and first person depending on their preference, and will shoot a lot of hideous demonic manifestations of evil before the game is done. The player is also able to transform into a hideous creature at key times in the game, which allows him to engage in intense melee combat. The game includes a morality system which records the player's actions during gameplay and changes the story accordingly, and also alters the player's creature form. Everything from the first The Suffering has been refined and turned up a notch for the sequel.