Getting mental illness right in gaming

Beata Gubacsi explores the representation of mental illness in Hellblade: Senua’s Sacrifice and other recent games in her regular column, Medical Humanities 2.0:

Recently, there’s been an increasing interest in the interactions of gaming, neurosciences and clinical psychology: virtual reality technology has become a significant part of experimental treatment of combat related PTSD, providing palliative care, and mobile gaming apps, such as the Sea Hero Quest, are assisting researchers with collecting data for dementia and Alzheimer’s research. This interest is possibly an outcome of a large-scale discussion and debate over the representation of mental illness in survival and psychological horror video games, starting with a “scandal” in 2013.

“Madness” and asylums have always been a go-to trope of Gothic and Horror tradition and they’ve become almost synonymous with the increasingly popular survival horror genre in gaming. The Silent Hill games can be seen as the first successful psychological horror game. The classic Silent Hill 2 (Konami, 2001) and P.T. (Kojima, 2014) seemed to have balanced artistically between amalgamating body horror with the protagonists’ alcoholism, repressed sexual desires, grief and guilt. On the other hand, games like Outlast (Red Barrels, 2013) and Evil Within (Bethesda, 2014) have been criticised for their portrayal of mental illness.

The debate over mental health and gaming has started and gained momentum after the release of the indie creation, Outlast, in 2013. The game is set in a derelict asylum where patients are depicted physically deformed and monstrous, and they are either catatonic or violent towards the player or fellow inmates. The criticism opened up the possibility of debunking urban legends surrounding mental health as it can be read an insightful piece by Jack Yarwood, “Mental illness in video games and why we must do better”, quoting James Harris, the head of communication for the Mental Health Foundation:

“In gaming, and more widely film, the backdrop of an abandoned asylum or casting a psychiatric patient as the principal villain is a common theme. Whilst acknowledging that the creator’s intention is not to increase stigma but rather to entertain, by default they are helping to perpetuate the stereotype that there is a correlation between people living with mental health problems and violent behaviour. The reality is, however, that people with mental health problems are more likely to be victims of violence.”

The heavy backlash the game received for the pejorative representation of mental illness also inspired a creative response from independent game developers in the form of the Asylum Jam. The Asylum Jam has been running successfully since 2013 in each November, challenging developers to create games depicting mental illness avoiding the tropes of asylum and dangerous inmate. Even outside of the Asylum Jam, there is an increasing number of narrative driven games (as far as I can see, mainly but not exclusively indie), such as Layers of Fear, The Town of Light and Unravel, which seek to represent various mental health matters from bereavement and trauma to schizophrenia and psychosis experimenting with new concept designs and game mechanics either sticking to horror elements or discarding them altogether.  The consensus of the debate was the current aesthetic and socio-political narrative surrounding mental health has to change, and, in this context, indie and AAA game developers have to find new ways of telling stories about sufferers, and more importantly, to those living with mental illness.

Hellblade: Senua’s Sacrifice (Ninja Theory), a story-driven indie horror game, appeared in this particular context in 2017, signalling a relevant step in getting closer to creating a more inclusive and less harmful representation of mental illness. The developers explain in one of the many, warmly recommended “Development Diaries”, that early on, they made two conscious decision: first, they were seeking to tackle the challenging theme of mental illness and second, they wanted a female lead even though games with female lead provenly sell less. Accordingly, Senua’s character has been initially modelled and designed as someone who suffers from anxiety, depression, delusion and hallucinations. The developers, a team of approximately, 20 people, wanted the game to be an accurate experience of psychosis and trauma.

In order to “get it right”, the Ninja Theory reached out to the Wellcome Trust, global charitable organisation, one of the biggest investors in health related research, and worked in association with experts like Professor Paul Fletcher, neuroscientist at the University of Cambridge,  and the University of Durham’s Hearing the Voice research team, relying on actual accounts of people suffering from visual and auditory hallucinations. While the research definitely shows in the hair-raising sound system and the atmospheric visual puzzles, I find it more significant that the developers took the experiences and descriptions of actual sufferers into account in order to achieve an accurate demonstration of the symptomatology of psychosis, which is one of the most misrepresented forms of mental illness in or outside of gaming. In doing so, the now multiple award-winning (5 BAFTA-awards) game also introduces significant technological novelties and improvements in the fields of facial animation, motion capture and especially sound effects.

The breath-taking graphics of the Unreal Engine is immersive, creating an organic and eerie atmosphere based on Celtic-Viking lore. The playable character is Senua, a Celtic warrior who seeks to redeem her murdered lover by retrieving his soul from Hel. Throughout the three trials navigating the gameplay, the traumatic events of Senua’s childhood resurface, revolving around her relationship to her father, and most importantly, mother, who was also a suffering from psychosis. There is no mini map or health bar in the game, the player has to listen to the voices interacting with Senua, guiding, comforting or threatening her. The game develops anxious feelings and confusion in the player, who does not have the usual tutorial to ease into the game, by making the player look for signs, establishing the rule “never trust what you see” early on. However, while the game has been criticised for the underwhelming and repetitive combat mechanics, it was praised for the moving acting and voice acting, the show-stopping motion capture and visuals, and the innovative game mechanics giving a uniquely empathetic, thought-provoking impression of experiencing psychosis.

As far as I know, this has been the first instance of this type of large-scale collaboration and, without doubt, a valuable precedent. The gaming industry and the players now have a new standard set in terms of representing and communicating mental health. Recent news suggests that the studio might remain a relevant contributor to mental health discussions. In the beginning of November 2018, Ninja Theory announced Senua’s Scholarship, a funding available for mental health professionals to support their training, further encouraging research in the therapeutic potentials of gaming. This great news was followed by another remarkable gesture for encouraging future co-operation between gaming and health professionals: the teams of Ninja Theory and the Cambridgeshire and Peterborough NHS Foundation Trust, including Professor Fletcher, have been honoured by the Royal College of Psychiatrists, and been awarded with the title “Psychiatric Communicator of the Year”.  It will be exciting to see Ninja Theory’s next project and I hope it will be similar to Hellblade. The next step would be working on inclusiveness: designing games for consumers with mental illness.


Photo by Hardik Sharma (@v4ssu) on Unsplash

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