Chapter 9, ''Despair'' / ''Karma'' takes place roughly two hours until dawn. The player takes control of Ashley as she, Sam, and whoever is alive between Chris and Emily, make their way to the Sanatorium; Chris, if he was left behind, Mike as he walks through the Sanatorium, and Sam searching for Mike. Jess also makes her first physical appearance since Chapter 4; if she is still alive at this point, waking up from her unconscious state.
- The chapter's title depends on the first choice in the Eighth Therapy Session.
- If you choose "They hurt me", you'll get Karma.
- If you choose "I didn't hurt anyone", you'll get Despair.
- This marks Jessica's first appearance since Chapter 4.
- Not being quick enough in decisions will cause Mike to be attacked, and the screen to go black, but he cannot actually die in this part.
- This chapter has a total of 11 collectibles able to be found.
- Two of them can be found in Chapter 5.
- With the repeated clues, this chapter has the fourth most number of collectibles able to be found.