Jodie Austin

Jodie Austin (Ph.D) is an Assistant Professor of English at Menlo College in the U.S. Her research and teaching interests focus on issues related to the medical humanities, digital technology, and socially just writing practices. Her chapter on surgery, amputation, and disability in 17th century medical texts will be appearing in the forthcoming volume Performing Disability in Early Modern English Drama from Palgrave Macmillan. She earned her Ph.D from Brandeis University in the U.S. and recently completed a research fellowship at Harris Manchester College at Oxford University in the UK.

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“The hardest battles are fought in the mind”: Representations of Mental Illness in Ninja Theory’s Hellblade: Senua’s Sacrifice

by Jodie Austin


This paper explores the videogame Hellblade: Senua’s Sacrifice (Ninja Theory, 2017) through a disability studies lens in order highlight the unique challenges associated with representations of psychosis in fictional, immersive gameplay environments. Throughout this paper I employ close reading strategies to critically examine specific scenes from Hellblade that alternately subvert or uphold stereotypical representations of psychosis; furthermore, I acknowledge the largely positive effects of the designers’ collaboration with stakeholders in the mental health community. However, I note the difficulties associated with framing psychosis as a conventional disability in theoretical discourse and call for the continued collaboration between the humanities and the medical sciences to promote scholarship that does not inadvertently perpetuate stigmatizing tropes. Lastly, I also argue for an active divestment of the term “madness” in the humanities and note the potential for videogame studies to establish a scholarly standard for doing so.

Keywords: disability studies, immersion, ethical representation, psychosis, stigma, neurodiversity in videogames



Released on August 8, 2017, Hellblade: Senua's Sacrifice (Ninja Theory) chronicles the epic journey of Senua, a Pict warrior who battles mythological characters from Norse lore during an epic quest to save the soul of her dead lover, Dillion. With Dillion’s skull in a bag at her side and a sword in her hand, Senua contends with Norse gods, ministers of the undead and the literal voice(s) of her conscience. More specifically, she experiences both auditory and visual hallucinations; the result is a game experience that is as compelling as it is profoundly disturbing. With stereophonic whispers and shouts that both taunt and admonish the player, the game's dramatic appeal pivots directly on the simulation of disorientation and psychological distress. As an added element of narrative tension, the player also learns early on that Senua has been infected with a creeping "dark rot" that threatens to destroy her mind should she be defeated in combat too many times.

In many ways the development and release of Hellblade marks a significant cultural benchmark for videogames, the mental health community and disability scholarship. Poised as a game changer within the entertainment industry, Hellblade’s pronounced commitment to aesthetic and clinical accuracy deliberately floats the possibility that popular games might allow players to better understand the experiences associated with psychosis and other mental disorders (Antoniades, 2018). The game itself was a critical success, maintaining a “Very Positive” rating on Steam as of September 2020 (“Hellblade: Senua's Sacrifice on Steam”). It also garnered five BAFTA awards (“Hellblade: Senua’s Sacrifice Scoops five BAFTAs,” 2018) and was lauded as "a masterclass of atmosphere, storytelling, and the marriage of mechanical and conceptual design" by IGN (Tyrrel, 2018). What such accolades fail to capture is the game's unique attempt to immerse the player in Senua's world of psychosis -- a mental condition obliquely referred to as "the darkness" in the game. During production, the game's creators alleged close collaboration with multiple psychologists, academics and even the Wellcome Trust in order to hone an accurate depiction of the protagonist's pathology (“Hellblade: Senua’s Sacrifice Scoops five BAFTAs,” 2018).

Nevertheless, the game's dramatic conflation of mental disorders with infection and putrefaction demands a closer scrutiny of its videoludic elements and thematic engagement. Ultimately, this paper argues that Hellblade represents one of the more sophisticated virtual representations of mental illness, through which players might better understand and even empathize with the experience of psychosis. Simultaneously, I also highlight the unique challenges associated with representing mental disorders that are, in some cases, characterized by the inability to distinguish reality from hallucination. Although I maintain that Hellblade is a sophisticated representation of a character experiencing a form of one what might call psychosis (Arciniegas, 2015), I also argue that challenges remain in representing specific mental disorders in videogames -- a medium that, by definition, actively subverts distinctions between reality, fiction and personal agency. Hellblade’s reliance on powerful metaphorical elements to represent Senua’s mental state, as I contend, risks undermining an otherwise laudable exploration of mental health as something other than abject debility.

Throughout the game, Senua is said to suffer from a creeping "darkness," implying a parallel between mental and physical deterioration and the inevitable loss of her humanity. The characterization of disordered thinking as an infection or sickness risks pathologizing Senua’s perception of the world as a distorted and malignant barrier standing between the heroine and refreshing lucidity. Senua’s quest thus becomes more of a journey toward reason, or as health and social care researcher Tom Grimwood (2018) argues, a form of “heroic madness” that must be overcome (p.312). While heeding the power of compassion and hope in the treatment of mental health issues, I acknowledge the work of game scholars Sarah Gibbons (2015) and Kelly M. Hoffman (2019) and argue for the need to balance sensitivity and medical accuracy with the desire for narrative closure in videogames that depict psychosis and related disorders. Concurrently, I call for scholars in the humanities to remain mindful of inadvertently replicating problematic and historically rooted rhetoric in their own analyses of videoludic, literary, and cinematic texts.

Representing mental illness

Mental illness scholarship within the context of digital media studies remains in a complex state of self-definition. Despite active conversations around representations of mental illness and cognitive difference in television and film (Davis, 2017; Ellcessor & Kirkpatrick, 2017; Livingston, 2004), videogame studies represent a newer and, in many ways, theoretically fluid subject area encompassing a wide range of methodologies. To this end, analyses of mental illness representations in videogames should continue to acknowledge the contributions of disability studies and media studies in a holistic fashion. In social sciences, research into the prevalence of mental illness tropes and stereotypes has provided helpful guidelines for coding related stereotypes (Shapiro & Rotter, 2016; Ferrari et al., 2019). Adopting an interdisciplinary approach with an eye towards aesthetic engagement, videogame scholar Diane Carr has provided essential frameworks for considering depictions of disability within the context of storytelling, embodiment, and ludology (2014, 2019, 2020). Indeed, such discussions remain urgent as best practices within game design and game discourse are continually revisited. With an eye towards promoting advocacy within games journalism and stakeholder communities, for example, Sky Anderson and Karen Schrier (2021) offer comprehensive recommendations for reformulating disability discourse within and around the gaming industry. Nevertheless, additional work remains in terms of hermeneutical approaches to videogames and representations of mental illness specifically. As noted by Carr (2020), “Humanities research at the overlap between game studies and disability studies has the potential to problematize clinical perspectives within game studies, and to help make visible the extent to which ‘ideologies of ability’ (Siebers 7) depend on the abjectification of disability” (p. 425). In “Ability, Disability and Dead Space,” (2014) Carr puts representation back into the spotlight by focusing on the game’s abjectification of bodily difference as the stuff of horror. Even as she focuses on somatic difference, her examination thus provides a crucial model for how humanities scholars might better deconstruct modes of seeing (or unseeing) cognitive difference within the game world. In terms of neurodiversity, Hoffman (2019) focuses on player reactions to games that feature representations of mental illness, providing much-needed insights into the dialectic between characterization, gameplay and audience reception.

In essence, scholars working within videogame studies and media studies as a whole are uniquely positioned to revisit historical critiques of mental illness depictions in Western visual culture. As Sander L. Gilman (1988) reminded readers in Disease and Representation: Images of Illness from Madness to AIDS, artistic representations of madness from the 16th century onward tend to privilege the eye of the ostensibly healthy (European) viewer, who consequently serves as an adjudicator between sane and insane views. Such depictions, Gilman asserts, offer a reassuring form of social demarcation as the insane Other is made legible (Gilman, 1988, p.48). More recent work in the field of art history has suggested that the popularity of such depictions remains intact. Ruminating on a modern toy company’s production of a teddy bear wearing a straitjacket, Jennifer Eisenhauser (2008) asks the fundamental question: “Why is there such a pervasive desire throughout history to depict mental illness and what contributes to the maintenance and repetition of these images?” (Eisenhauser, p.16). Indeed, the value of Eisenhauser’s query lies in part in its insistence on social responsibility; there are real consequences, as she suggests, to this “visual culture of stigma” (Eisenhauser, 2008, p.13). Although the answer to Eisenhauser’s question regarding the persistence of these tropes is beyond the scope of this particular paper, I would argue that the medium of videogames should be included in any conversation regarding the ethical responsibilities borne by producers of visual culture.

In terms of acknowledging the power of videogames to both stigmatize and empower players, the partnership between media studies and disability studies is all the more crucial. The mutual relevance and even urgency of such a collaboration has been acknowledged by Elizabeth Ellcessor and Bill Kirkpatrick (2017), who cite the uniquely somatic engagement prompted by media technology: “Media technologies themselves raise further issues of materiality and embodiment: how we interact with buttons, dials, or gaming consoles; how we plug in earbuds or position ourselves to view screens; how manufacturers imagine the bodies that will engage with their creations; and in countless other ways” (p.16). As observed by M.D. Schmalzer (2020), so called “janky” controls and gaming mechanisms may, quite powerfully, flush out assumptions about player bodies and sensory experiences, especially where the experiences of “standard subject positions” are concerned. While questions around said subject positions necessarily concern bodies -- and minds -- of all types, disability studies scholars themselves have acknowledged the underrepresentation of mental illness within the discourse. The somewhat indeterminate status of mental health issues as a subset of disability studies has, in part, stemmed from the desire to avoid further stigmatization and issues of conflation (Scott & Bates, 2017). As Benjamin Fraser (2018) argues in Visual Culture, Disability Representations, and the (In)Visibility of Cognitive Difference, scholarly discussions around representations of disability in the media have historically centered on physical disability rather than mental health issues and cognitive difference. According to Fraser, this discursive lacuna potentially risks promoting an ableist agenda by removing cognitive difference from the operational framework of disability studies: “It is possible, then, that disability scholarship has
-- inadvertently, perhaps -- aided in constructing a homogenized view of disabled populations by prioritizing the exceptional physical body” (Fraser, 2018, p.37). Fraser’s argument thus makes clear the necessary touch points for any serious investigation into depictions of mental illness in modern media; in order to levy a claim regarding cognitive difference in visual culture, scholars must adopt a discursive stance regarding the status of cognitive studies qua disability.

By engaging in a complex and narratively sympathetic depiction of mental illness, Hellblade attempts to distinguish itself by subverting toxic stereotypes around psychosis in particular. As noted by Manuela Ferrari et al. (2019), Hellblade: Senua’s Sacrifice seeks to “disrupt mental illness stereotypes and potentially contribute significant new understandings of the illness experience.” Indeed, rhetoric centered on compassion and awareness appears frequently in the production notes as well as the promotional material for the game itself, suggesting that this was a conscious decision on the part of the studio. In the behind-the-scenes documentary “Senua’s Psychosis,” for example, game creator Tameem Antoniades suggests that one aim of Hellblade is to promote awareness around mental illness (Antoniades, 2018). As Antoniades acknowledges, “Mental illness such as psychosis is still taboo and rarely acknowledged in a century of cinema, nevermind the new medium of games. Where it does feature, it often conflates psychosis and psychopathy, associated with a lack of empathy” (Antoniades, 2018). While the validity of Antoniades’ claim regarding the conflation of clinical terminology is not disputed, he simultaneously proffers game design (and Hellblade specifically) as an exceptional platform for shifting discourse surrounding mental illness. Indeed, Antoniades’s reference to the “new medium of games” (emphasis added) suggests Ninja Theory’s conscious marketing of the game as pioneering in both technological form and expressive content. Videogames, his comments imply, have the potential to blaze new narrative trails while positioning gameplay as an act of community good. The effort has not gone unrecognized by game reviewers; as Vice reviewer Danielle Rindeau (2017) notes:

I haven't seen a game inspire quite this much applause, albeit tempered, for its ability to make you relate to a character's delusions in a sympathetic and pragmatic manner. There's much more to be said about how exactly this works, particularly as people explore a number of different reasons why they see gaming as the ideal medium for this story.

Coupled with Ninja Theory’s Hellblade website (filled with interview footage, development diary vlogs and links to mental health resources), the creative director’s commentary goes beyond typical addenda and into the realm of the deliberately paratextual (Genette, 1997). The multidimensional nature of the production -- the game, the commentary, the behind-the-scenes footage and the outreach efforts -- renders the gameplay experience a complete media experience. The degree to which these efforts are read as sincere, especially by scholars and stakeholders within disability/neurodiversity communities, is another matter. As Anderson and Schrier (2021) note, commercial and journalistic messaging that tends towards the “self-congratulatory” may actually hinder “the impetus to continue to address accessibility needs” (p.10). Within the context of Hellblade’s elaborate production, it becomes difficulty to separate out any hints of self-congratulation from the representational world of the game itself. For this reason, more collaborative methodologies are needed to even begin answering the following question: Who most benefits from a playable fiction in which the protagonist appears to have an acute thought disorder?

Subverting the psycho-killer

As illustrated, Antoniades’s commentary suggests the production team’s desire to avoid conflating psychosis with psychopath in their conception of Senua. The tendency to confuse the two terms is common, even in academia, underscoring the need for critical precision on the part of theorists wishing to adopt the language of neurocognitive studies or psychology (Berg et al., 2013). Before considering critiques of Hellblade, this paper therefore acknowledges Ninja Theory’s relative success in challenging many of the problematic stereotypes related to figurations of the “psycho,” “psycho-killer” and “madwoman” through a nuanced and informed characterization of its protagonist. In most instances, the character of Senua transcends and even actively resists familiar troping as a “psycho-killer” or, to use the terminology of Steven E. Hyler et al. (1991), the “homicidal maniac” (p.1044). As seen in films such as Psycho, Nightmare on Elm Street and Friday the 13th, such stereotypes frequently conflate schizophrenic-like behavior with homicidal, sadistic or supernatural behavior (Hyler, 1991, p.1045). In the case of Psycho, as Hyler et al. argues, the film “perpetuates the myth that schizophrenia means split personality and that one of the personalities is a violent, dangerous menace to society” (1991, p.1045). Notably, the binaural chorus of voices that whisper, speak and occasionally shout at the player does simulate some of the hallucinogenic symptoms frequently associated with schizophrenia and/or similar thought disorders (Bentall, 2006; Arciniegas, 2015).

At times, Senua also appears to speak in a voice that is not her own, evoking the aforementioned stereotypes around personality schisms. Contrary to the homicidal/sadistic associations cited above, however, the game takes care to highlight Senua’s compassion and deep empathy toward other beings, real or imagined. She refers to Druth, a ghostly narrator, as an “old friend” and appeals to him when she seems frightened or confused. As a means of explaining his desire to accompany her on her quest, Druth cites the empathy she displayed toward him while he was living: “You listened, when everyone else laughed. My people paid a heavy price.” Although Druth urges Senua to “make the Northmen feel our fury!” the player learns through flashbacks that Senua’s fighting skills were learned from her romantic partner during a time of relative peace. Far from the bloodthirsty warrior, Senua is instead depicted as a shy and self-effacing martial prodigy -- more misunderstood than misanthropic.

In addition to showing empathy and tenderness, Senua endures debilitating bouts of guilt and remorse; a merciless killer she is not. At a critical juncture in the game, she experiences an apparent flashback of a plague epidemic in her village. Insects buzz across the screen, and the landscape becomes hazy with the miasmic vapours of rot. We hear, through the precisely engineered soundscape, the gassy moan of a nearby swamp. When the scene eventually cuts, we see Dillion, Senua’s lover, kneeling in front of the body of his father, who appears wrapped in the same shroud covering the corpses stacked around the village. Whether it is the voice of memory or of delusion, we hear Dillion accusing Senua of bringing the plague to their village through her “curse,” which presumably refers to her mental illness. The camera then orbits to a first-person vantage point while Senua pleads for understanding and the screen trembles as if to simulate the effect of her heaving. This scene exemplifies how the game’s manipulation of perspective invites the player to palpably suffer Senua’s sense of guilt and loss as she does. Indeed, her capacity for empathy proves to be the primary driving force behind her quest to ensure Dillion’s spiritual salvation, even at the cost of her own life.

Arguably, Senua’s gender also serves as a means of putting distance between the protagonist and any notions of psychopathy. Women have often been depicted in visual media as crazy, but the appellation of “psycho-killer” is one that has been conventionally applied to men. Within the examples of homicidal maniac archetypes identified by Hyler et al. (1991) for example, only one (the eponymous maniac cook from D. W. Griffith’s 1909 film) is a woman (p. 1045). This is not to say that women have been exempted from problematic archetypes related to mental disorders. Within the context of dramatized mental illness, female characters have, in fact, been rendered archetypical simply by nature of their being female. As video blogger Anita Sarkeesian (2013) has demonstrated through her meticulously curated Feminist Frequency vlog, the virtual bodies of female game characters are often relegated to the role of damsels in need in saving or -- as an act of extreme objectification -- fetishized corpses. In contrast to these damsels, sexy corpses and seductive female patients (Hyler et al. 1991), Senua’s eros hardly figures into the picture. When the action is slowed in Hellblade (using Senua’s unique “focus” ability during combat), the dramatic backlighting and POV-heavy composition emphasize her acrobatic prowess rather than her body’s shape. In the scenes that do feature Dillion, he appears primarily as an ethereal figure whispering reassuringly from the shadows. Senua’s passion for Dillion, in short, is steadfast but hardly sexually charged.

While the matter of Senua’s eros is certainly a worthwhile topic for future discussion, I wish primarily to focus on how her gendering and/or desirability appear unbound from any question of sanity within the game compared to conventional depictions of women with mental health issues, especially in popular culture. Unlike the DC-universe character of Harley Quinn [1], Senua’s cognitive identity -- or identity as a whole -- remains distinctly apart from any erotic identity. Without conferring judgment on the ludological merits of either character, I would argue that Hellblade swaps the crazed nymphomaniac for the noble warrior; while both represent recognizable archetypes, the latter is freed of gendered referents.

Perhaps most importantly, Senua’s identity as a warrior stands apart from her pathology; unlike the character Ellie (The Last of Us, The Last of Us: Part II), who channels her psychological trauma into bloodthirsty rage, Senua engages in battles that represent a series of practiced trials unmotivated by her mental state. As with The Last of Us, however, our glimpses into the interiority of Senua bind the player to a world in which violence is deeply consequential, even trauma-inducing in its own right. Even so, Hellblade wisely sidesteps the trap of casting Senua’s psychosis as the direct product of violence; she has not been “driven mad” by her environment or by the loss of her lover. Rather, the hallucinations she experiences seem to have preceded the events of the game. In an earlier encounter the game suggests that Senua’s abilities were inherited from her mother, who refers to Senua’s “sight” in a brief flashback. As one of the narrators informs us, “she taught Senua to see the weave that binds the world together and it was beautiful.”

Illusion versus Delusion

It is precisely at this moment, however, when psychosis is recast as second sight, that the game’s relationship to mental illness becomes more fraught. While Senua’s delusions range from the reassuring to the terrifying throughout Hellblade, the inherently gamified experience of navigating from one vision to another suggests that the difference between transcendence and trauma is a matter of reference. From the perspective of her nurturing mother, Senua’s delusions represent a gift; for her sadistic and closed-minded father, her very existence is a curse. The risk lies in the potential reframing of Senua’s delusions as a sort of enlightenment, straying into the territory of the “supercrip,” well known to disability-studies scholars. In his survey of the critical discourse around supercrips, Sami Schalk (2017) notes “how these representations focus on individual attitude, work, and perseverance rather than on social barriers, making it seem as if all effects of disability can be erased if one merely works hard enough” (p.73). As a journey-oriented game, epic challenges are to be expected; the game thus lends itself well to narrative analyses that incorporate Aristotelian conceptions of mimesis and catharsis (Cullen & Vaughan, 2021). Nevertheless, as Gibbons observes (2015), video games retain the power to serve as educational and even therapeutic tools without employing problematic tropes of psychological “overcoming” (p.35), reducing complex and often chronic cognitive conditions to narratively resolvable obstacles. Indeed, Christina Fawcett identifies such a trajectory in “American McGee's Alice: Madness Returns and Traumatic Memory,” describing the experience as “psychologically hollow” for the player while “providing the player with goal-oriented satisfaction” (p. 501). Although American McGee’s Alice (Rogue Entertainment, 2000) and American McGee’s Alice: Madness Returns (Spicy Horse, 2011) precede Hellblade, the games share some similarities in that they feature female protagonists with traumatic pasts and mechanisms for psychological reconciliation. Where the Alice franchise opts for a more fantastical and sometimes exaggerated aesthetic, however, the creators of Hellblade make a concerted push for verisimilitude. As such, they, arguably, bear significant responsibility in heeding the active dialectic between clinical and fictional discourse (Carr, 2020; Donaldson, 2002).

Concerning verisimilitude, Senua’s own auditory hallucinations constitute a more ludologically destabilizing presence than perhaps even the game creators intended. The voices emerge in the game’s opening scene, as Senua is shown paddling a log boat in the distance. The first speaker’s voice seems to fill the expected role of the omniscient narrator when she asks, “Hello? Who are you? Doesn’t matter. Welcome.” She then goes on to reassure the player, “You’re safe with me. I’ll be right here, nice and close so I can speak without alerting the others.” The narrator’s reference to “the others” immediately keys the player to the many levels of metacognition evoked by the game. As the virtual camera (Krichane, 2021) orbits Senua’s boat, she casts furtive glances in “our” direction, at once threatening to dissolve the distinction between player, audience, narrator and delusion.

The scenes that feature visual hallucinations thus underscore the difficulty of applying conventional character analysis techniques to a heavily mediated player experience in which disorientation is meant to reproduce an emotional state. At one point, Senua navigates a labyrinthine forest while tracking the elusive Valravyn, the Norse god of battlefield carrion. The challenge lies in making the most of Senua’s ability to see clues, symbols and even faces in the landscape around her, re-creating the phenomenon of pareidolia -- the tendency to see meaningful images in inanimate objects (Takahashi & Watanabe, 2013). All the while, the player is encouraged to locate the invisible Valrayvn by homing in on his unearthly song. Despite the lack of “gamerly” markers in Hellblade (e.g., mini-maps, compasses and quest logs), the game’s proceduralizing of sensory vigilance commands attention to the sheer number of interpretive layers interposed between the player and the environment. More specifically, the player’s encounter with Valravyn alone includes at least ten identifiable hermeneutic layers. [2] First, Valravyn arrives to us through the process of creative mediation by Ninja Theory’s creative concept team. Second, Senua learns of Valravyn’s history through Druth, who offers her fragments of Norse mythology. Perhaps most critically, Senua’s “perception” of Valravyn constitutes a misnomer on multiple levels: to say that she perceives is to disregard the obvious fact of her fictionality. Valravyn could, depending on the hermeneutic filter we choose to apply, represent an illusion, a creative artifact, a myth or all of the above. To its credit, the game seems to signal the limitations of mimetic power through Druth’s own warnings to Senua. Throughout Senua’s search, Druth admonishes her: “Illusion hides the path to Valravyn. Don’t trust your eyes. Find another way to see the truth.” His injunction directs the player to understand that visual trust within the videogame, paradoxically, remains contingent upon sensory distrust.

Thus, to play Hellblade is to engage in an act of imaginative faith for both Senua and the player. Senua’s “world shaped by nightmares,” as the game’s narrator describes it, presents a unique analytical challenge. In terms of procedural rhetoric, it could be argued that players are trained to regard the world as the fictional Senua does: filled with furtive signifiers that continually expand new ways of seeing in a manner similar to what Daniel Vella terms “the ludic sublime” (2015). While there are physical/geographical limitations to the world that Senua inhabits, the game invites players to imagine Senua’s mind as a boundless space of subliminal possibility governed only by tests of faith. The question of whether we should indulge this way of seeing is never quite resolved, however. Regardless of however much one may empathize with Senua and her quest, the player is unquestionably forced to subscribe to an expansive yet frequently disturbing perspective -- or quit playing the game altogether.

While it should be understood that Hellblade was not designed to privilege player agency, I would argue that the choice to feature psychosis as a reigning theme in the game finds an uneasy refuge in the concept of procedurality, or even immersion. In lieu of a journey toward cognitive insight, Hellblade risks railroading the player experience by treating each delusional indulgence as a progression checkpoint. In no way is this more apparent than in scenes that feature the ominous creeping rot or, simply, “the darkness.” Senua first contracts the creeping rot after speaking to an unseen foe; clutching her hand in pain, she goes on to fight her first battle while a cacophony of voices ring in the player’s ears. After Senua suffers defeat, we watch as the rot envelops the rest of Senua’s body. Her boots step into the frame; from a low angle we see her kneel at the side of her own corpse as a narrator intones, “A vision of what’s to come. Poor Senua. The darkness does not bargain. It does not reason. It is rot. And now it has taken hold.” Soon after, flickering text appears on the screen: “The dark rot will grow each time you fail. If the rot reaches Senua’s head, her quest is over.”

Ultimately the conflation of unreason (and potentially psychosis) with darkness, rot and monstrousness risks shuffling the game back into the lineup of historical depictions of madness that rely on similar tropes, including those identified by Ferrari et al. (2019) in “Gaming with Stigma: Analysis of Messages about Mental Illnesses in Video Games.” Writing from a mental health research perspective, the authors locate consistent patterns in representations of mental illness in popular videogame titles, noting, “Psychosis and other severe mental illnesses were typically associated with paranoia, lack of control, being followed by a ‘dark presence,’ [or] having an infection” (Ferrari et al., 2019). Along similar lines, Tom Grimwood (2018) notes the ubiquity of “an uncontrollable (or less controllable) ‘other’ whose relation to the player is usually embedded within a wider moral choice within the game’s plot” in his study of “heroic madness” in videogames (Grimwood, p.312). Representationally speaking, Senua’s psychosis thus bears hallmarks of all three elements at once: her irrational thoughts manifest as stalking foe, strangling shadow and fast-growing malignancy. Ludologically speaking, her “illness” is as fictionalized as Senua herself; for these reasons this paper avoids any claims regarding the accuracy or realism around diagnosable illnesses. And yet, the public-facing paratextuality of Ninja Theory’s website campaign makes it impossible to avoid situating Hellblade within a larger discourse around representations of mental illness.

While there is nothing inherently wrong with players or even characters likening the experience of psychosis to a shifting darkness or a spreading rot, such metaphors potentially enable the narrative more than they do Senua as a character. As the darkness spreads, both the heroine and the player are, arguably, driven by parallel goals with different motives: Senua wishes to avoid psychological peril; the player wishes to avoid restarting the campaign. For these reasons, players may be rendered suspicious of the game’s dramatic reveals; the ultimate arbiter of Senua’s fate is none other than Ninja Theory, and the darkness nothing more than a programmatic construct with a suffering hero at its center.

Thus, it is all the more important for producers to heed the complex meta-relationship between players, characters and game narratives in games that emphasizes derealization as an effect as well as a form of lived experience. At their core, immersive experiences represent an exercise in manipulation -- sensorily, narratively and psychologically. As documented by Petri Lankoski (2011), the degree of “engagement” between the player and PC (player-character) is multifaceted and dependent upon factors ranging from the perception of goal achievement (p.296) to empathy (p.299). Within the context of mental health, however, the degree and manner in which psychological manipulation is deployed within an immersive gaming experience deserves critical attention. For this reason, Lankoski’s appeal to the discourse of “engagement” rather than “immersion” may be better suited to discussions of games such as Hellblade, which actively promote experiences of derealization. While certainly immersive, the power of Hellblade as an interactive experience is in what it demands from the player as well as its protagonist. Accordingly, players who identify with the cognitive experiences enacted within the game may be especially attuned to the sensitivity with which games deploy manipulative tactics. In a review for Polygon, writer Dia Lacina (2017) reflects on her feelings of betrayal after learning that the rot’s progression -- and the game’s permadeath mechanic -- was a fiction:

The lie is injected by an external authority who has agency over not only Senua, but the player. It’s a manipulation that’s only purpose is psychological destabilization. Even though I can see the well-meaning intentions behind this trick, in a game about the debilitating consequences of abuse and mental illness, it’s an extremely inconsiderate trespass.

Lacina’s charge against the game underscores the potential fallout of building a game in which destabilization functions as the primary mechanic (Lacina, 2017). Indeed, the theme of lying/dissemblance is a major one within the game, as if to refigure the player’s sense of derealization into an aesthetic decision; the player has been lied to, but then so has Senua. In the case of Lacina’s gaming experience, the indictment is of psychological rather than narrative manipulation. In other words, the issue becomes one of ludological consent. When readers experience “irritation” at the “narrative fraud” in Ian McEwan’s Atonement (2001), for example, their reactions are the result of a perceived breach in literary convention -- the unspoken contract that exists between authors, narrators and readers (Jaëck & Schmitt, 2019, pp.355-356). As the reaction to Hellblade suggests, however, the conventional or even ethical obligations game designers have to players and their psychological well-being is less defined; when the dramatic structure buttressing the game’s power turns out to be illusory, players may find the game’s implicit messaging around empathy and compassion equally flimsy. Nor, as game critic Jason Faulkner (2017) observes, is it entirely clear why psychosis features so heavily in the character development of Hellblade to begin with. While rich opportunities abound in videogames for representations of psychosis alone, the game’s insistence on metaphorizing Senua’s illness risks diminishing the unique nature of the challenges the character faces. As Faulkner wonders, “If you took away the conceit that Senua lives with psychosis and replaced it with real demons, ghosts or dark magic, how different would the game be?” (Faulkner, 2017). Indeed, the game’s frequent conflation of illness with darkness, monsters and especially rot suggests that much would remain the same, aesthetically speaking.

What would certainly differ is the game’s relationship to its audience and stakeholders. According to Joseph Fordham and Christopher Ball (2019), Hellblade may very well serve as an example to other game developers looking to portray issues related to mental health in a realistic and compassionate manner. Citing Ninja Theory’s commitment to transparency and collaboration, the authors conclude that the game developer’s “consultation of mental health professionals, scientists, and those with various mental illnesses throughout the development of Hellblade resulted in an accuracy and educational legitimacy rarely seen in mainstream video games” (Fordham & Ball, 2019, p.11). As previously mentioned, Ninja Theory’s push for paratextual and educational engagement compels an analysis that accounts for the interstitial relationship between players, the production team and stakeholders or consultants. Consequently, critical disciplines, from game studies to disability studies, should continue to acknowledge “video games and their players” as “a network of actors that both work together and influence each other” (Sotamaa, 2014, p. 7).

Conclusion: furthering the discourse

In sum, titles like Hellblade test the status of videoludic discourse to describe the cognitive experiences of neurodiverse fictional characters. As Fraser (2018) persuasively argues, both media producers and critics of visual media bear the responsibility of observing and challenging problematic representations of cognitive disabilities. Scholars who engage in popular forms of media analysis, especially those that relate to narrative theory, should be cognizant of the historically problematic connection between the narrativizing of “madness” and the perpetuation of problematic stereotypes. In regard to Hellblade, such attention is especially crucial when analyzing videogames that simulate forms of disordered thinking, psychosis or hallucinations. In particular, I would suggest that the field of humanities -- not simply medical researchers -- has everything to gain from codifying an ethics of mental illness representation in immersive gameplay and an active divestment of the words madness and psycho without historical or medical contextualization.

Accordingly, analyses of Hellblade lend insight into the challenges of presenting mental illness as something other than a “narrative prosthesis” -- the concept explored by David Mitchell and Sharon Snyder (2001) to describe the ways disability appears in a fictional text solely for the purpose of advancing the plot, or as a shorthand for a character archetype. As Mitchell and Snyder (2001) observe in Narrative Prosthesis: Disability and the Dependencies of Discourse, such texts often reduce the disabled body to an “overdetermined symbolic surface” (p.64). The question of who “owns” Senua’s psychosis in Hellblade is also always clear, given that her fictional character is very much informed by the lived experience of real-life human beings (Antoniades, 2018). More generally, the difficulty of finding an inclusive discursive approach to the subject of mental illness in videogames is exacerbated by the continual refiguration of illness as poetic “madness” -- and its gendered associations.

The poeticizing of mental illness, even in the writing of literary scholars seeking to call out problematic tropes, has been criticized within literary studies. In “The Corpus of the Madwoman: Toward a Feminist Disability Studies Theory of Embodiment and Mental Illness,” for example, Elizabeth J. Donaldson (2002) revisits the scholarship around Jane Eyre in order to argue for rhetorical precision and a framework that accounts for realistic embodiment apropos of mental illness representations. As she convincingly asserts, “Fictional representations of madness have a way of influencing clinical discourses of mental illness and vice versa” (Donaldson, 2002, p.22). Donaldson’s injunctions echo those of Susan Sontag (2001), whose Illness as Metaphor made a foundational case against the poeticizing of illness (with particular attention paid to cancer). Sontag sums up her thesis in famously powerful and succinct terms: “My point is that illness is not a metaphor, and that the most truthful way of regarding illness -- and the healthiest way of being ill -- is one most purified of, most resistant to, metaphoric thinking” (Sontag, 2001, p.3).

The risks associated with reducing otherwise complex characters like Senua to the corporeal embodiment of a nuanced and often deeply troubling form of mental illness are significant. Writing from a personal perspective, Lacina (2017) criticizes the game’s implied moral that psychosis should be viewed as a gift rather than a curse:

Perhaps my hyper-vigilance has kept me from danger; it’s also made me lash out at perceived but unrealized threats… I’m certain my mental illness has never benefited me or society (a claim Ninja Theory co-founder Tameem Antoniades muses on at the end of a documentary feature included in Hellblade). I’m not some mystical aberration helping the world progress; I’m just a girl trying to live as best I can.

Debates surrounding the distinction between dramatization and romanticization of mental health issues in art are by no means settled. As this paper was being drafted, the editors of Vogue Portugal decided to pull the cover of the “Madness Issue,” following backlash from readers (“Vogue Portugal Pulls Controversial Mental Health Cover”, 2020). Featuring an image of a young woman sitting in a bath in a sanitarium-like setting, the July 2020 issue was criticized by mental health experts and readers for its stereotypical imagery (“Vogue Portugal Pulls Controversial Mental Health Cover”, 2020). The increasing ubiquity of immersive games may very well mean that more interactive representations of mental illness will be produced; these, in turn, may actively challenge and even promote strategies for resisting harmful stereotypes around mental illness (Thoits, 2011). Combining elements of gothic fiction and Lovecraftian horror, Red Hook’s Darkest Dungeon (2016), for example, satirizes many of these same elements (including sanitariums) while slyly acknowledging the meta-gaming dilemma tension between narrative determinism and play. While the Vogue Portugal Madness Issue represents an attempt by a popular magazine to engage in a serious discussion of social issues, its use of the nonclinical term madness underscores the degree to which attitudes toward mental illness remain deeply entrenched. In short, much work remains to be done.

As videogames like Hellblade become increasingly sophisticated in illustrating cognitive complexity, scholars have an obligation to maintain critical frameworks that acknowledge the degree to which lived experience has become intertwined with game production and reception. In its attempts to reproduce rather than simply capture some element of psychosis, Hellblade represents a compelling testament to the continued need for collaboration across research disciplines if scholars in media studies are to keep pace with the media itself. As previously noted, Carr (2014, 2019, 2020) has engaged proactively with issues regarding videoludic representation through the lens of disability studies. Meanwhile, scholars such as Anderson and Schrier (2021) and Schmalzer (2020) have highlighted issues that relate more directly to accessibility, involvement, and the privileging of standard player bodies. The success of collaborative efforts between media theorists and disability studies will, however, depend on the inclusion of mental illness as a recognized disability rather than an aesthetic trope. Significantly, the work of Gibbons (2015) and Hoffman (2019) continue to provide excellent models for including neurological diversity in discussions related to disability studies and video games. Ultimately, critical approaches to videogames that take a cue from such scholarship in remaining sensitive to neurodiversity issues provide a much-needed alternative to “madness” as a discursive trope. With the much-anticipated release of Hellblade II on the horizon (Mercante, 2019), scholars from all disciplines will have ample opportunity to revisit the story of a lone Pict warrior whose neurodiverse characterization has captured the attention of those well beyond the imagined land of Helheim.



The author would like to thank the anonymous reviewers of this article who offered thoughtful suggestions and words of encouragement. Members of the gaming community, including Adam Brockup, were instrumental in providing support and perspective during the revision process. This article is dedicated to those in the mental illness community who continue to help empower, educate, and support one another.



[1] Harley Quinn’s videogame appearances frequently embody the patient-as-seductress archetype in the comic-inspired series Batman: Arkham (Rocksteady Studios, 2009).

[2] Suggested layers of interpretive mediation include: player as consumer; player as gamer; Player as agent of Senua’s character; The virtual camera; Valravyn’s “agency”; Senua’s psychosis; Senua’s “Greek chorus”/narrators; Senua’s; physical sight; Druth’s narrated historical context; Programmatic execution (design); Norse mythology; Popular Culture.



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