Interview with Paul Fletcher
In 2017, Hellblade: Senua’s Sacrifice, by Ninja Theory, was released for PC and PlayStation 4, later making its way to Xbox One, Nintendo Switch and Xbox Series X/S. The game was remarkable for dealing masterfully with a difficult topic, psychosis. It was made by a relatively small team that counted with advice from specialists in mental health and by people living with the condition to properly represent it. The game received wide acclaim for its portrayal of psychosis, the acting of Melina Juergens (who plays Senua), and also technical aspects (notably, the voices or “Furies”).
This year saw the release of the sequel Senua’s Saga: Hellblade II for PC and Xbox Series X/S. This new game continues Senua’s story and her struggle with psychosis and, once again, the team at Ninja Theory (now part of Xbox Game Studios) relied on a group of experts offering advice and their experiences.
Among the experts was Dr. Paul Fletcher, a Professor of Health Neuroscience at the Department of Psychiatry, University of Cambridge, UK. Dr. Fletcher was part of the team in the development of both games and kindly agreed to an interview. So, we took the opportunity to learn more about his participation in game development, the medical understanding of psychosis and its in-game depiction, and much more.
So please read ahead. But do keep in mind that, while we do not have any major spoilers here, this interview is best enjoyed after playing at least the first game.
Before we start talking about games, would you kindly give our readers some background on your academic and clinical work?
I trained in medicine and then specialised in psychiatry, practising as a full-time clinician in north London before becoming involved in research. My current role is a mixture of clinical and research work and I also do some teaching. My main interest has always been in trying to understand the brain processes that are necessary to perceiving and making sense of reality and, in particular, how alterations in those processes might lead to psychosis.
As a university professor, it must have been rather surprising to be contacted by a video game company – and to act as an advisor in a very complex matter on top of that. How did that happen exactly?
Yes – it happened almost exactly a decade ago (2014) when the Ninja Theory team were just beginning to develop what would become Hellblade: Senua’s Sacrifice. They wanted to begin by understanding more about it and came across my name as someone in the vicinity who does clinical work and research in the condition. So, they just sent me a short email asking if we could talk a bit and I came along to their studio. I was impressed straightaway by what they were trying to do and the care that they wanted to put into it. So, it grew and developed out of that.
What kind of advice and information were you providing during game development?
To begin with, we organised a few meetings in which I talked about the basic neuroscience of psychosis, what the symptoms are and so forth. That led on to more in-depth discussions about how, for all of us, with or without psychosis, the experience of reality is constructed from within. It’s not just through the evidence of our sense that we comprehend the world around us. We also use our past knowledge to shape reality to our expectations. Recognising this – and the processes by which the brain constructs our model of reality – we can begin to get closer to understanding what happens when people experience an unshared reality, which is what psychosis is.
The term used to refer to Senua’s experience in the game materials is ‘psychosis’, but that term encompasses lots of different things. Would you be able to give us a quick primer on what is psychosis and what are its most common causes and symptoms?
In some ways, psychosis is a loose descriptive term. It basically refers to the experience of an unshared reality – one that other people don’t concur with and may not understand because it can seem so bizarre and lacking in evidence. Importantly, it’s not just some vague or faint imaginary experience but it can feel absolutely real and unquestionable. Doctors typically think of psychosis as having two main components: hallucinations, which are altered perceptions (perceiving, hearing seeing, touching, tasting, smelling) things when there is no external cause, and delusions, which are unusual beliefs, sometimes bizarre and frightening, which seem to arise without good evidence and which can be very much out of keeping with what the person would normally believe. So, for example, a hallucination might consist of one or more voices talking to the person and a delusion might be the belief that they are being hunted or persecuted by neighbours.
It’s a description, not a diagnosis, and it can have many different causes. Typically, people think of it occurring in the context of a serious mental illness like schizophrenia. But it can also be found in neurological and physical illnesses. Isolated symptoms of psychosis (like hallucinations) are thought to occur, in relatively mild forms, in healthy people under certain conditions (stress, trauma, sleep deprivation, sensory deprivation) and, of course, it can occur due to drugs.
Besides yourself, there were also further advisors who brought in their personal experiences with psychosis. So, there was an interplay of both science and lived experience informing game development, plus all the narrative and gameplay aspects, and actors. How was your experience in working with that group?
From a very early stage, the Ninja Theory team wanted to involve people with experience of psychosis, and this has been a commitment that they have honoured throughout the past 10 years. We ended up having fascinating meetings in which personal experience, neuroscience, clinical experience and art, acting and gameplay were all brought together. These meetings would lead to design and creation by the Ninja Theory team, which would then be shown and discussed at subsequent meetings. The whole process was iterative, and the lead designers made sure that everyone had a voice that was listened to.
It is clear that everyone involved put in a lot of effort and attention in the games and treated the topic with care and respect. So, how good a representation of psychosis does Hellblade offer?
From my perspective, the games have deeply embedded certain principles of understanding how we make sense of the world and construct our own realities into the story, gameplay, and audiovisual design. They have also done some truly remarkable things in representing individual symptoms (like auditory and visual hallucinations), to the extent that I have found them enormously helpful in communicating my work to students and the public. More than that, and viewing the games as a whole, they have created a deeply empathic representation of what it might be like to live in an uncertain, unreliable, frightening and confusing world and to have to battle through it, which is what the individual with psychosis may have to do every day. More importantly, the people who contributed their own experiences of psychosis to the game have been explicit that the game really does convey the experiences in a way that is compelling, honest, and respectful. That means a huge amount and it’s been incredible to see this view echoed by those who weren’t involved in game design but have their own experiences of mental illness and distress, in themselves or in loved ones.
In Senua’s Saga, it feels like Senua is on another “stage” of dealing with her psychosis in comparison to the first game. Is that something real, in the sense that is based on real-world data?
Yes. One of the earliest principles of the story was that there would be no “miracle” recovery but, at the same time, Senua would come to terms with her experiences and learn to live with them and manage them, just as people may have to do in real life. As the story moves into Senua’s Saga, there has been a change in her outlook. She still has the voices (“the Furies”) with her and she is still experiencing a reality that differs from the ones experienced by those around her. But she has more agency. She isn’t deeply enveloped by the Darkness that she was forced to battle through in Senua’s Sacrifice. She can recognise and integrate with the realities of others around her. This is a known experience in the evolving experience of psychosis. People may come to inhabit a dual reality and to have to somehow balance what they experience with the idea that others may reject that reality and may have very different perspectives on the world. This can be uncomfortable and difficult, and I think that Senua’s Saga has done some very interesting things to represent that and explore it. For example, at a simple level, sometimes Senua’s voices will challenge or argue with the voices of the people around her, urging her to distrust them. This is a very real experience in psychosis and can be very hard to deal with.
The two Hellblade games reached a wide audience and brought people in contact with several aspects of psychosis. Do you think Senua’s story might help the public to understand better what psychosis entails and perhaps remove the stigma and prejudice from it?
That has been our hope throughout. It’s important to know that the initial aspiration of the game, as I understood it, was not to serve as some documentary or “edutainment”. Rather it evolved to represent an unusual and frightening experience as truthfully and respectfully as the medium and the art could allow. I think that, in telling a story with these principles in mind, Ninja Theory have created an experience that offers a powerful urge towards empathy for people in the throes of psychosis. By treating Senua as a complex, frightened and confused, but ultimately heroic character, they’ve created a perspective on psychosis that resonates with my clinical experience of the courage, grace and dignity of people dealing with this condition. Telling stories in this way and with this level of care seem to me crucial in fostering empathy and ultimately challenging stigmatising attitudes.
Has people dealing with psychosis contacted you because of the Hellblade games? And if so, do you know if the games have helped them to understand themselves better?
Yes – people have contacted me and, in much greater numbers, have directly contacted the studio. I have been really touched by how positive they have been about the validating effect the game may have on their views of themselves and their experiences. People have spoken of having experienced a sense of shame and of trying to keep things secret and have found that the game challenges that by recognising and representing their struggle. One of the very consistent messages is that, by creating this representation, and representing inner experiences and struggles in a way that can be seen, heard and shared, they have experienced a sense of relief in being able to show it to others and say, “this is what it can be like for me”.
Now going the other way around, what do you think about using video games as part of the treatment of mental health issues?
I think there is a huge, and as yet largely untapped, potential in what video games can bring to clinical sciences. We could use games to replace the standard (and boring) psychological tasks that measure cognitive function, we could develop much more sophisticated and precise measures of how people approach problems and challenges in different ways. Ultimately, gameplay has a big learning component and I envisage that games can provide a setting in which psychotherapeutic tools could be offered in ways that are creative and effective. Indeed, I have been working with Ninja Theory to look at ways in which gameplay could help people to learning to regulate their responses to stress and this is an exciting possible avenue.
Besides raising awareness, do you think Hellblade is a good tool in teaching? Do you use it in your classes?
In the past, my lectures tended to be restricted to describing psychosis and giving examples of first-person written accounts. Over the last decade, my teaching has much improved by incorporating segments from Hellblade to convey much more vividly what the auditory and visual experiences might be like. It has been extraordinarily useful to me in my classes.
Do you have any final words for the gamers out there who want to learn more about the topic?
With the release of Senua’s Saga, Ninja Theory created a 20-minute video documentary talking about psychosis. It includes the voices of people who have experienced psychosis as well as of the artists and writers who worked so hard to incorporate these experiences into the game. I would strongly recommend it. In it, I talk about the neuroscience of psychosis and of how we construct our reality all the time – you can always fast forward through those bits but make sure you listen to the artists and those with experience of psychosis as that is really powerful and interesting.
ABOUT THE INTERVIEWEE
Dr. Paul C. Fletcher lives in Cambridge and spends his spare time reading novels and poetry, playing video games, and long distance running with a ridiculously fit Springer spaniel called Idris and an even fitter wife called Nicky – both of them can run further and faster than he can. He used to play a lot of football (the British kind) but is getting too old now, so he watches it and pretends that he used to be better at it than he actually was. He’s played both Hellblade: Senua’s Sacrifice and Senua’s Saga: Hellblade II and finds them immensely powerful and emotional experiences. He feels incredibly fortunate to have been a tiny part of a team that is so incredibly talented, motivated and inspired.