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How Cambridge game developer worked with Addenbrooke’s psychiatrist to address psychosis



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The inclusion of gameplay dynamics which help address anxiety in the hugely successful video game Hellblade: Senua’s Sacrifice has resulted in a PhD course on ‘Using video games to manage physiological and emotional responses’, Prof Paul Fletcher revealed in a recent webinar.

Prof Paul Fletcher is Bernard Wolfe professor of health neuroscience at the University of Cambridge
Prof Paul Fletcher is Bernard Wolfe professor of health neuroscience at the University of Cambridge

Prof Fletcher is Bernard Wolfe professor of health neuroscience at the University of Cambridge and an expert on psychosis and schizophrenia. In 2014 he started working with Cambridge games developer Ninja Theory to develop Hellblade: Senua’s Sacrifice, which was launched in 2017 and has now reached six million players. In 2018, Microscoft acquired the company.

The game follows Senua, a Pict warrior who has to face down otherworldly entities on her way to Helheim to retrieve the soul of her dead lover – whose death she witnessed – from the goddess Hela. Along the way she hears disconcerting and accusatory narratives, inner voices and ‘messages’. The voices are troubling, malevolent and distressing for Senua and therefore – potentially – the player, yet they must be navigated to achieve her goal.

The collaboration, Prof Fletcher explained in the online talk, included himself, a Ninja Theory team including mental health advisors Michael Lafond and Kathy Jones, plus mental health consultant Jenny Esson, who sadly lost her life to coronavirus aged 45 in 2020. Also on the creation panel was a small team from Cambridge-based members of Recovery College, which provides online courses and resources for those experiencing mental health issues.

As a psychiatrist, Prof Fletcher called psychosis “a hugely complex condition, basically a reshaping of reality, and sometimes a loss of reality”. The symptoms are “delusions and hallucinations”.

‘Hellblade: Senua’s Sacrifice’, by Ninja Theory, portrays some intense states of mind
‘Hellblade: Senua’s Sacrifice’, by Ninja Theory, portrays some intense states of mind

“Psychotic episodes are far more frequent than we think, even with people not suffering a psychotic illness,” he says. “They are potentially terrifying and baffling, and one of the consequences is a huge degree of stigma.”

Prof Fletcher has made it his goal to challenge this stigma – though doing this in a video game setting was an unusual choice.

“I was aware that video games don’t have a great history,” he said, quoting games commentator Patrick Lindsey’s 2014 view that “gaming’s favourite villain is mental illness and it needs to stop”.

The way to turn it around, Prof Fletcher decided, was “to take the symptoms, such as the voices, and make them very real and relevant – which is what psychotic people experience in real life – and create a sense of what it might be like”.

“It was an opportunity to reach a much bigger audience with these ideas,” he said, “and reach people who wouldn’t normally engage with my work.”

The work was a combination of “yes, neuroscience, and also people who had had direct experience of mental illness and are trying to forge their own recovery”.

Prof Fletcher showing a scene from ‘Hellblade: Senua’s Sacrifice’ during his ‘Cambridge Biomedical Campus on Tour’ talk
Prof Fletcher showing a scene from ‘Hellblade: Senua’s Sacrifice’ during his ‘Cambridge Biomedical Campus on Tour’ talk

Gameplay, however, always came first.

“It’s a game, not ‘edutainment’,” Prof Fletcher stated. “The science and the clinical aspect were embedded in the game but it had to work as a game. It’s the story of a person, not an illness.”

The online talk, part of the Cambridge Biomedical Campus on Tour series, backed by the Cambridge Independent, included videos of real-life people affected by psychosis.

“Everything is in bits,” says one sufferer. “It’s a photo you can’t put back together. It’s frightening.”

Another reported that they were OK with the voices but “it’s the anxiety that’s the problem”.

Such impressions are replicated in extracts from Hellblade shown to the webinar’s attendees.

“Fear will swallow you,” Senua hears. “Darkness becomes a part of who you are. There’s no way back to who you once were. There’s nothing to go back to now anyway.”

In another clip Senua hears: “The gods will use their power. You will die here and there’s nothing you can do to stop it.” At which point Senua finds her voice and yells: “Shut up!”

There are psychological challenges in Ninja Theory’s ‘Hellblade: Senua’s Sacrifice’
There are psychological challenges in Ninja Theory’s ‘Hellblade: Senua’s Sacrifice’

“It seemed to catch fire after it was released and the reviews, even in the mainstream media, were amazing,” noted Prof Fletcher. “The Guardian called it ‘a masterpiece’. It won five BAFTA Game Awards.”

Then came the emails and tweets of thanks for putting a face to something previously hidden.

“It saved my son’s life,” said one.

Interest from the scientific community soon followed.

“Could video games and technology be used as a way of changing their state of mind and improving things?”

A basic understanding of neuroscience can help, says Paul.

Prof Fletcher shows a message of thanks during his ‘Cambridge Biomedical Campus on Tour’ talk
Prof Fletcher shows a message of thanks during his ‘Cambridge Biomedical Campus on Tour’ talk

“We’re profoundly influenced by the messages we receive from our body – they’re very visceral. The trouble is that most people don’t understand this, so maybe if you can give them recognition of their bodies and how messages work we can help understand and improve their condition.”

That meant wiring up gamers to check heartbeat and breathing levels, and making more use of virtual reality (VR) headsets.

“The VR helps create and represent the physiological stages of anxiety,” says Prof Fletcher.

If psychosis and anxiety can be exacerbated by video games, perhaps they could also be reduced.

“The physiological data is reflected back at the gamer, so people are getting more in touch with how their bodies are responding.”

One of ‘Hellblade: Senua’s Sacrifice’ more uplifting scenarios
One of ‘Hellblade: Senua’s Sacrifice’ more uplifting scenarios

The research now is on the effects of using VR for experiences of peace and calm. This has included visuals of “sitting in a boat on calm water in a gentle environment” and then, through the VR, “a breathing pattern being taught”. Perhaps such relaxation breaks could become part of a standard gaming experience?

“We have created a beautiful interface which we’d like to share with other scientists,” says Prof Fletcher, adding that when it comes to mental health “it is often approached in a tokenistic way”.

He concludes: “The companies that will be successful will make mental health a core part of the process, though that comes at a cost – this game took three years to develop.”

- Read about Lucie Daniel-Watanabe’s PhD work here.



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