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.
The story picks up right where the first game left off. The player once again takes on the role of Torque, former death row inmate with a mysterious past. Now returning to his home town of Baltimore, Torque must confront the mysterious Blackmore, the man who may or may not have killed Torque's family. But it won't be easy, as the hideous creatures from the first game have now overrun the streets of Baltimore. Will Torque finally be able to come to grips with his past?
In the German version, all blood effects which emerge after direct player interaction were removed. Most of the scripted sequences in-game are not effected, but most corpses which can be found in the levels are not mutilated. A detailed list of changes can be found on schnittberichte.com (German).
Gamers who finished the first game can use their saved games to begin Ties that Binds on Evil or Good morality based on the ending they got in the first game. Alternatively, players can finish Ties That Bind once and unlock to ability to start the in any of the three morality alignment.
On the PC version, the first Suffering and the patch must be installed first followed by Ties That Bind. Installing the sequel first and predecessor later would cause glitches in the first game.