Lessons Learned From Mental Health Portrayals in Video Games

TECHNOLOGY IN PSYCHIATRY

A review of the video game Hellblade: Senua’s Sacrifice and implications for psychiatry.

Dr. Edrei recently completed his Ph.D. at Tel-Aviv University and currently teaches a course on gaming that university. His publications on interactive storytelling, video games, and virtual narrative appear in Ctrl-Alt-Play (McFarland); A History of Evil in Pop Culture (ABC-CLIO); and a forthcoming book, Cityscapes of the Future (Brill). Dr. Packer is a psychiatrist and a frequent contributor to Psychiatric Times. She is the author of several books pertaining to psychiatry and popular culture.

Psychiatry and media have long been strange bedfellows. There are several reasons why. For one thing, psychoanalysis and cinema emerged within a year of one another as the 19^th century ended. That chronological correspondence allowed each to influence or interact with the other and increased one another’s awareness of such turn-of-the-century innovations. Much attention has been showered on psychiatry’s representation in cinema.^1-3

Video games now merit the attention of psychiatric practitioners as well as the public-and financial forecasters.¹ Video games are currently three times as profitable as films. Earnings for youthful esports champions exceed their parents’ wildest expectations, according to the Wall Street Journal.⁴ The Entertainment Software Association (ESA) 2015 report notes that 42% of Americans (150 million people) devote at least three hours a week to video games.⁵ Over 91% of persons under age 17 years play video games regularly (and that number is increasing rather than decreasing). Yet over 55% of practicing psychiatrists are over age 55,⁶ making them less likely to have as much personal experience with video games as their younger patients, peers, or progeny, and making the profession in general in need of updated information on this medium.

When video games do attract the attention of psychiatrists, that attention often revolves around potential adverse effects of gaming⁷ or about premorbid psychopathology that predisposes persons to overuse video games.⁸ Occasionally, we hear about negative portrayals of psychiatric patients or practitioners in video games, such as Arkham Asylum (a spin-off of the Batman Universe and today’s top-grossing video game). Arkham revolves around a bedlam-like asylum for the “criminally insane,” where psychotic or simply sociopathic psychiatrists are committed to the very same institutions they administer and are locked in wards with murderous and often infamous mental patients (eg, the Joker, Penguin, Mad Hatter, the Riddler). We find allusions to video game addiction in American psychiatric literature, and rehabilitation programs for such addictions have popped up. This is especially true in South Korea, where nationwide high-speed internet connectivity is conducive to gaming.

DSM-5 failed to add this proposed diagnosis to the standard nosology but instead listed it as “a condition for further study.” Yet as of 2018, World Health Organization (WHO) broke with the American Psychiatric Association’s lead and is set to include “gaming disorder” in the updated and upcoming 11^th International Classification of Disease (ICD-11).⁹

At a time when other novel forms of media are being touted for treatment of psychiatric disorders (such as virtual reality [VR] treatment for phobias), it may be useful to revisit a new breed of video games that may have value as teaching tools, if not necessarily as treatment tools.

Hellblade: Senua’s Sacrifice is one such example. Developed by Ninja Theory and published in August 2017, the game’s bombastic title belies its thoughtful, emotionally resonant narrative that stands out even in the age of increasingly cinematic game experiences. It relies on extensive neuroscience-related research for the project.

The player controls Celtic protagonist Senua, a warrior whose lover Dillion has been sacrificed to the Norse goddess Hela at the hands of Viking marauders. To reclaim his soul, Senua embarks on a solitary journey to Helheim, fighting through hordes of masked Northmen.

Taken in isolation, the plot offers little innovation: while some critics have praised the game for inverting the gender roles of the stereotypical revenge plot, and casting the avenging protagonist as female, the structure of the game’s story follows the expected route. However, the presentation of said plot is key to understanding the game’s appeal. The opening sequence, in which Senua quietly rows to the shores of outer Helheim, immediately distinguishes itself from its predecessors via three points of interest.

The first concerns the narrator who introduces herself as the camera closes in for its first look at the game’s protagonist. Unnamed, the voice addresses the player directly, speaking in a low whisper so as not to alert “the others.” A host of whispers immediately follow-some asking questions, some mocking Senua, some reiterating her mission statement and determination. The voices overlap, speak over each other, and at times argue with each other. As the cacophony continues, Senua looks around apprehensively, indicating to the player that she can hear every word. As the introduction winds to a close, just before the player gains control of Senua’s movements, the protagonist indicates that she can hear the narrator-and that she is aware of the player as well, just another voice in her head. Though these voices are referred to within the fictional world as Furies (a clear reference to the Greek tradition of conflating femininity and madness), the game is quick to demystify Senua’s condition: she suffers from schizophrenia, a condition later revealed to have been inherited from her mother.

The second revelation becomes immediately apparent as the voices persist in speaking over the narrator’s exposition: in a behind-the-scenes feature, director Tameem Antoniades explains that the discordant voices were recorded using binaural audio. Thus, when the player hears these voices, they move from the left speaker/earphone to the right, alternating in volume and distance. This is meant to mimic the aural symptoms of schizophrenia, which has been frequently misrepresented in visual media such as film and television.

The third innovation becomes apparent during the game’s initial credits, as the first name listed is not Antoniades’ or a producer’s, but rather Paul Fletcher, a professor of Health Neuroscience from the University of Cambridge. The feature provides more details on Professor Fletcher’s role as Mental Health Advisor and elaborates on Antoniades’ determination in addressing the subject of mental illness from the rare position of factual accuracy rather than dramatic license. Indeed, the game goes so far as to differentiate the symptoms of Senua’s mental state: she has heard voices since early childhood, while the later-onset visual hallucinations that plague her in the present may be the by-product of another psychotic break or PTSD-type flashbacks from any of several traumatic events (including Dillion’s murder), sensory deprivation during her solitary journey or complicated bereavement or more. Psychiatrists will reflexively speculate about the differential diagnosis of new-onset visual hallucinosis, which could result from any number of medical etiologies, or may simply be an allusion to Celtic myth. The ambiguity adds to the game’s appeal.

As a narrative medium, video games have been alternatively praised and criticized for their attempts to discuss ‘serious’ subjects such as suicide, rape, trauma and mental illness. While some developers have grounded their fictional representations in a measure of emotional veracity, Ninja Theory’s effort here is remarkable for the extent to which the studio solicited, retained, and followed the advice of professionals in the field, and consulted advisors who suffered from similar conditions. Thus, the game aspires to a more faithful and honest depiction of an oft-stigmatized mental illness-a depiction that may yield positive effects as an educational experience, given the increasingly ubiquitous hold immersive video games have on the public. This game may also aid in the education of mental health professionals who strive to understand their patients’ perceptual, emotive and cognitive experiences as much as their neurochemistry.

References:

1. Packer S. Cinema’s Sinister Psychiatrists: From Caligari to Hannibal. Jefferson, NC: McFarland; 2012.

2. Packer S. Movies and the Modern Psyche. CT: Praeger; 2007.

3. Gabbard GO, Gabbard K. Psychiatry and the Cinema, Second Edition. Washington, DC: American Psychiatric Press, Inc.; 1999.

4. Needleman S. Video stars have fans, fortunes-and utterly baffled parents. The Wall Street Journal. January 4, 2018. https://www.wsj.com/articles/videogame-stars-have-fans-fortunesand-utterly-baffled-parents-1515085499. Accessed February 26, 2018.

5. More than 150 million Americans play video games [press release]. Washington, DC: Entertainment Software Association; April 14, 2015. http://www.theesa.com/article/150-million-americans-play-video-games. Accessed February 26, 2018.

6. Hawryluk M. Supply of psychiatrists shrinks. The Bulletin. August 11, 2016. www.bendbulletin.com/home/4557462-151/supply-of-psychiatrists-shrinks. Accessed February 26, 2018.

7. Young K. Video games: recreation or addiction? Psychiatric Times. April 20, 2015. http://www.psychiatrictimes.com/adhd/adhd-associated-video-game-addiction. Accessed February 26, 2018.

8. Fuerst ML. ADHD associated with video game addiction. Psychiatric Times.http://www.psychiatrictimes.com/adhd/adhd-associated-video-game-addiction. May 9, 2016. Accessed February 26, 2018.

9. Wakefield J. Gaming addiction classified as disorder by WHO. BBC News. January 2, 2018. http://www.bbc.com/news/technology-42541404. Accessed February 26, 2018.