Three Big Takeaways From Hellblade’s Psychosis Expert

Hellblade: Senua’s Sacrifice is a bold experiment for Ninja Theory for several reasons. In addition to serving as a test case for an indie that can compete with triple-A games in terms of presentation and gameplay, the game stars a character who struggles with a frequently misunderstood phenomenon: psychosis. The studio regularly met with people who experience a variety of psychoses, including auditory and visual hallucinations, to ensure that the in-game representation was as accurate as possible. Ninja Theory also consulted with Paul Fletcher, a neuroscience professor in Cambridge’s Clare College to learn more about psychosis from a medical perspective. We spoke with Fletcher while in Cambridge, and left with a better understanding of psychosis – which doesn’t necessarily align with how it’s frequently portrayed in popular culture. 

Fletcher says he was drawn to psychosis as a medical student, where he worked with a patient who believed that he was getting messages from his television. “I was absolutely fascinated by what could make somebody have such different perspective on the world, when actually they’re getting the same evidence as I was,” he recalls. Fletcher has spent his professional life studying and teaching his students about the phenomenon, which can affect all of our senses. 

Here are three highlights from our conversation:

Psychosis may not be what you think
The word “psychosis” may summon images of straitjackets and state-run hospitals, but that’s a misperception. To be fair, pop culture hasn’t done a great job of articulating what psychosis is, in favor of veering toward a couple of extremes. One example that Fletcher points to is a person who thinks that they’re a historical figure, like Napoleon. “That is an old trope that’s never really true,” he says. “People have different views about their own importance in the world and their own place, but it’s very rare that their actual self is altered.” 

Another misconception that people have about psychosis is that people who experience it are an inherent danger. “That’s an understandable mistake because people with psychosis can be shouting out and talking and can feel quite frightening, but they’re far more likely to have violence done to them than they are to do violence to people,” Fletcher says.

Psychosis is, put simply, a symptomatic description of being separate from the world – whether that’s seeing, hearing, or otherwise experiencing things that other people don’t. Fletcher says that much of a “normal” person’s experience is the result of absorbing and contextualizing the stimuli that we perceive from our various senses. “We all think that we’re peering at reality as though it’s laid out in front of us, but actually all we’ve got are these binary messages into our nerve endings,” he says. “They’re highly complex, noisy, and ambiguous, and we somehow assemble them into our model of the world. In that context, what’s actually happening a lot of the time is that perception itself is a controlled hallucination.”

A person who experiences psychosis interprets these stimuli differently from many of us. “Suddenly you start to notice all of these coincidences everywhere. Every time you moved your head, the trees would sway, and that might be really compelling that they were related,” Fletcher says. “Out of the small perceptual experiences could spiral these changes in the way you perceive the world. That’s central to some of the experiences that Senua has. Things are happening that are salient, and she’s trying to make sense of them.”

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Watch this video to learn from the game's creative director about collaborating with experts to make sure mental illness is handled honestly

It's been around for a long time
People who lived hundreds or more years ago may not have had the same medical vocabulary that we do now, but they grappled with many of the same mental-health issues. Psychosis is no different, according to Fletcher. “You can see reference to hallucinations in the ancient Greeks and beyond,” he says. “You can certainly see [it in Celtic cultures]. You can see even in that stage they were sort of dividing people up according to those who had what might be called a developmental disorder, they were learning disabled or didn’t have the mental capacity, versus those who, usually because of trauma or because of some sin that they committed, they had been robbed of their wits. That would be closer to the idea of psychosis.”

Fletcher is cautious about offering diagnoses across the span of centuries, however, to the point of not wanting to provide a formal diagnosis for Senua. “We sort of studiously avoided that, and I think partly because it would be a bit anachronistic. Schizophrenia is something that’s become a diagnosis in the early 20th century, late 19th century, so I think it’s hard to look back at different cultures and different times and say, ‘That’s that illness.’”

Games are a great place to explore the phenomenon
Fletcher had a familiarity with video games before Ninja Theory reached out to him – he played Red Dead Redemption when it came out – but he was still apprehensive about how the game would deal with the subject. “There was a slightly cautious element because of course a game with a character with hallucinations isn’t necessarily going to be a terribly sensitive representation of mental illness,” he says. "But I was also very intrigued.”

Once they met and Ninja Theory explained what they were attempting to do with the character, Fletcher says he was on board. He says the team took their responsibility seriously, finding ways to incorporate elements of psychosis such as hallucinations and pattern fixation into the game without seeming exploitative. “I’ve done scientific advisory work with people before, and sometimes what you get are people who want to make sure that they’re ticking the box and getting it right – not saying anything wrong,” he says. “I felt that there was a lot more to this than that.” 

More broadly, Fletcher says that he finds games a fascinating portal into how people perceive reality in the physical world. “You get set down somewhere, and you don’t have prior expectations. You have to sort of start from scratch and build up your expectations and use them to make sense of the next bit. In one way, it’s almost the best way I can think of replicating what a human has to do in moving about the world. I’m interested in how games are the ideal way to look at these sorts of things.”

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