Players who have a game save of the different endings of The Suffering can decide with which morality to start with, starting with a different morality changes the dialogue and intro of the game.
It is the sequel to The Suffering, and picks up after the ending of that game. The Xbox version of the game is not supported by the Xbox 360's backwards compatibility feature. The Suffering: Ties That Bind is a video game developed by Surreal Software and published by Midway Games, released in 2005 for the Xbox and PlayStation 2 game consoles as well as the PC.