Hellblade: Senua’s Sacrifice is one of the best games of the year, with its terrifying account of a warrior’s journey into the depths of the Norse underworld — and into madness itself.

The game from British game studio Ninja Theory came out on August 8, and if you haven’t played it yet, you ought to. I reviewed Hellblade in August and gave it a score of 95 out of 100, the highest I’ve given this year. But fair warning, it’s hard to experience because the depiction of psychosis of the Celtic warrior Senua is haunting, as she struggles with inner demons locked in a battle over her mind.

Senua’s story was created by a team headed by Tameem Antoniades, chief creative director at Ninja Theory. The labor of love took four years for Ninja Theory to make, and the studio infused the hack-and-slash fantasy game with a realistic depiction of a character suffering from psychosis — or seeing things in the world that aren’t real. Senua can’t tell whether the demons she sees with her eyes or the voices in her head are real or not.

Image Credit: Ninja Theory

To refine this story, Biomedical research charity Wellcome Trust gave Ninja Theory a $395,000 grant to do research on mental illness, and that helped Ninja Theory make such an ambitious and research-based game on its own as an independent studio. Ninja Theory’s Melina Juergens created a video documentary of the research and the game’s development, and the company even created a website to find out more about mental illness.

Ninja Theory combined that research about Senua and psychosis with the hellish environment and extremely detailed facial animations that looked completely real. As Senua descends into the underworld and does battle with monsters, you can’t really tell what’s real and what’s not. I talked with Antoniades for an in-depth postmortem on what the tale was about, how Ninja Theory made the game, what was real and what was fantasy, and what was the meaning of its cryptic ending.

For me, it was a rare pleasure to experience a work of art and then interview its creator about how it came to be. It is also gratifying to see that Hellblade is going to pay off commercially in profits just a few months after its publication.

Here’s an edited transcript of our interview.

Editor’s note: This story has narrative spoilers.

Image Credit: Ninja Theory

GamesBeat: Can you summarize how you made the game with the help of mental health experts, the folks from Cambridge University and Wellcome Trust?

Antoniades: Once we had decided that the game was about — it was more about fantasy and psychosis and how they relate to myth. Right at the start of the project, we knew it was not an easy subject to tackle. The potential for backlash, if we did it wrong, would be immense. We wanted to do our research.

We looked up who was local that could help us, and professor Paul Fletcher came up. We just Googled him. It turns out he’s a psychiatrist and a leading expert in psychosis, so we got in touch with him. He came to visit the studio. We also got in touch with Wellcome, the second biggest charity in the world, actually.

Both of those meetings went really well. Paul just talked to us. He gave us some pointers, some advice on what we needed to learn and understand. After meeting him, we wanted him to be on board as part of the team as a collaborator. Wellcome, at the same time, gave us a grant. It’s called a co-development grant, and I think it was either half a million dollars or half a million pounds. They did that, so we could consult with Paul and other groups. They encouraged us to meet with as many diverse groups as possible.

Through them, we were in touch with Recovery College East, the main collaborators. Tracey [Tingey], who runs this group, invited several people to the studio, all people who have lived experience of psychosis and mental illness. They were all willing to talk and share about their experiences. We kept coming back to them every two or three months or so, right from the time we announced the project. In the design stages in the project, we met with them, and we continued to meet with them. We’d show them what we were doing and talk to them about their experiences. Then, we folded that all into the game design and kept doing that until we finished the game.

The development of the game was very fluid. The story was developing as we were learning more. The gameplay and the levels and art were developed alongside their feedback. We also spoke to a bunch of other people. There’s a voice-hearing group called the Voice Collective, which is an interesting group. It represents voice-hearers, people who acknowledge that they hear voices but who do not subscribe to the idea that that makes them mentally ill. We met with a group of people who would describe themselves as severely mentally ill. It was quite a broad range of people and experts in the end.

This was largely thanks to Wellcome and Paul Fletcher. Wellcome gave us the funding with which to take our research seriously, and Paul gave us the guidance. He was like our mentor on the project with regards to mental health.

GamesBeat: Where did you pick up the initial empathy for a character like Senua? Psychosis tends to be attached to characters in fiction who are villains, not heroes.

Antoniades: That’s how it’s represented in most media, yeah. I think it’s not quite right. There’s a mix-up between the term “psychosis” and psychopathy. Psychosis is a break with reality. Psychopathy is a lack of empathy. Those two words are used interchangeably, even in documentaries about these subjects, and it effectively means that when you hear someone has psychosis, you think they’re psychopathic, which is a totally different thing. It basically means that if you hear voices, see visions, or have delusional beliefs, you’re automatically assumed to be dangerous. That’s where the trouble starts. It’s something I had to learn about as well, the distinction.

It’s a great disservice that the media has propagated. It’s probably caused a lot of suffering in people who experience these things. It makes them feel ashamed to admit that they have these conditions. For me, it was a learning process as well. I’m not ashamed to say now that I came into this from a position of real ignorance.

So yeah, to do a game where we try to get to the science and the truth behind it was illuminating. It didn’t take us, perhaps, in the direction that people would assume. It led us to a much more personal, introspective journey than we initially thought we would go on.

Image Credit: Ninja Theory

GamesBeat: At some point, did you know what you wanted to say with the game?

Antoniades: It developed. At first, I wanted to see if we could recreate the experience, to put yourself in someone’s shoes who experiences psychosis. On the surface, it’s a very visceral experience, being able to hear voices, to see visions. It’s a very literal experience. People talk about seeing demons, and they mean it. Strange belief systems, seeing signs and patterns everywhere, these are [things] that I thought — a video game is actually a good medium for this stuff.

As we did more and more talking, more interviews, the human cost came through. Then, it became more of a character study, dissecting her life. Senua is an amalgamation of a lot of people’s experiences. She could always see the world differently. She could always hear voices. But it took trauma, stigma, misunderstandings by her father and other people, to turn that into a negative experience, which then haunted her.

That mirrors what a lot of people experience. It’s not so much the symptoms that are the mental illness part, if you like. It’s the suffering at the hands of others that makes those symptoms intolerable or turns them negative in a way.

GamesBeat: I was fascinated by how you incorporated her ability to see the world differently into the puzzles. That was an interesting integration of the theme into gameplay.

Antoniades: It’s based on research that Paul Fletcher has done, where in tests, when you’re looking at random noise and you ask people whether they can see a hidden image or something in it, people that are predisposed to psychosis, if you like, pick out those patterns much quicker than the general population.

I actually think that a lot of those abilities to see patterns and stuff — it doesn’t indicate a mental condition at all. Some people are better at seeing patterns in the world than others. That doesn’t necessarily mean you’re psychotic. It’s a natural part of who we are and how we experience the world. But in extreme cases of psychosis, it’s very evident in people.

Image Credit: Ninja Theory

GamesBeat: Did you find that most people understood what you were trying to get, as far as feedback to the game?

Antoniades: I think I’ve been more than — I’ve been very surprised, to be honest, at how understanding people have been. I thought the game would be very controversial, that there would be a camp that’s dead against what we were doing, and there would be quite a raging debate over whether it’s morally right to represent these things in a video game, especially a video game about a warrior with a sword, given the associations with violence. In fact, the discussion around the game has been very mature and understanding, amongst gamers and amongst healthcare professionals.

As you know, the gaming audience can be quite harsh and brutal when you get into discussing things anonymously online. To see quite a mature conversation surrounding this and to see people who have been touched by the game — it’s a better outcome than I imagined was possible. I did have some crises of confidence making the game, just thinking, “How can this game possibly have a good outcome?” But thankfully, I’m satisfied. Some people have a counter-view on it, but that’s remarkably minor compared to the overwhelming positive reactions we’ve had.

GamesBeat: I saw one story that ran in Polygon from a person that had mental illness.

Antoniades: That’s OK. In my view, the game is hugely metaphorical. It’s not usual to have a film or a game that tells a story that’s so metaphorical. It’s open to interpretation. Every voice in reaction to that has validity. Her view is just as valid as every other player’s view. I did think there would be a lot more of that.

GamesBeat: Did you hear back whether people felt the game was therapeutic or something that mentally ill people maybe should not play?

Antoniades: The groups we spoke to throughout development, they were extremely open. They suggested we put in a warning at the start of the game because if you have experienced those things, it can be frightening. They asked us to put that warning in, but they totally encouraged us to go down the path we were going and to show it as they see it, as it is — show it in its true horror, if you like.

Image Credit: Ninja Theory

GamesBeat: It was validating for a lot of people?

Antoniades: Well, what was great was, once the game was out, we got so many messages, which we put into our accolades trailer. It felt like it would be flippant, when we made that trailer, to just put in press comments or whatever saying it’s great. We put in actual user comments, and we received so many of them. You’d struggle to read these letters without being moved. It really was affecting people.

The best way it seems to have helped people is that — the experience of psychosis and being stigmatized is so intensely personal that it makes you feel so alone in the world. To have something out there, an aspirational hero, a hero that’s not a victim — she’s a fighter — a hero that has these things and is able to move on and press forward and not give up, it’s rare. Just by existing, I think the game has made people feel like they’re not alone, or they shouldn’t be ashamed of this. If a game, of all things, can represent these aspects, then maybe, they’re not so unusual. We’ve had a lot of letters and emails from people who have used the game to make other people understand what they’re going through. I’d say that’s probably the best possible outcome for us.

I was also very worried about the subject of death, which is another subject we don’t talk about very often. It’s raised quite a lot in the game. I think I was worried that perhaps we should avoid that subject. The issues people have when they have severe mental health issues — they’re long-standing, ingrained, repetitive thought patterns that are really powerful. It’s not one game or one thing that will tip them over the edge. Whenever I had that choice — should we talk about this, should we put this in the game or not — I always fell on the side of truth. If this is what people go through, what they think, what they talk about to us in our interviews, then we’ll represent that, rather than trying to romanticize it.

GamesBeat: To you, is the world of Hellblade real, or is it a metaphor for Senua’s imagination?

Antoniades: A theme in the game is that no one’s reality is “real.” When you’re stepping into Senua’s shoes, you can only ever see her reality. There is no other reality that you can step into and say, “Aha, that was that, and this is this.” I would say that her journey is real, as in she is physically traveling. It’s not all a dream. I’ve said that much before.

GamesBeat: A fair amount of it is rooted in history, facts about the Vikings coming into the Orkney Islands and so on.

Antoniades: Yeah. The Vikings did land on Orkney, and they did replace the Pictish population. We don’t know how. There were trading routes between Britain and Scandinavia. We brought on a professor from Cambridge, Dr. Elizabeth Ashman Rowe — she’s an expert in Celtic and Viking history — as a consultant. I likened the fantasy part of the game to something more like Don Quixote, where he’s fighting a windmill, but he sees it as a giant. There’s an interpretation of the world that’s fantastical, but it’s rooted in a real place.

Image Credit: Ninja Theory

GamesBeat: I hope you’ve accomplished something for people.

Antoniades: I hope so, too. I’m already super happy about the response so far. I do genuinely believe that it’s given a voice to some people that have been ignored. We’re all very proud of what we’ve accomplished on this game. I’m grateful to our fans, the people who’ve loved the game. It’s a great feeling, especially coming off DmC.

GamesBeat: There was a surprising controversy about the permadeath aspect of the game. I wonder if you could address that in some way. If anything made the internet crazy, it’s that.

Antoniades: Yeah, there was that. I think it made a top-five trending topic on Twitter in the U.S. and U.K. But it was there — we debated it internally as well, whether we should do that or not. We did it because it was in service of the story and the experience. We wouldn’t have done it just to make the game hard, needlessly hard. We felt justified that it added to the experience while knowing that some people wouldn’t like it.

We’ve done a lot of those things in this game. Not having a HUD, having the camera so close, the incessant voices — all of these things sound like terrible ideas when you first raise them. We knew we were trying to, first and foremost, make an experience work. If it was in aid of that experience, we put it in, knowing that it’s not going to be a game for everyone. We knew that. That’s one of the benefits of not going down the triple-A publishing route. We don’t have to be like everyone else. We don’t have to please everyone. I think the consensus is pretty good now. People get it.

GamesBeat: The facial animations turned out to be amazingly effective. Did you discover in parallel here that you could do faces that crossed this uncanny valley?

Antoniades: It was a group effort. You were there at the GDC session. It was a really concerted effort, with 3Lateral, Cubic Motion, Epic, and ourselves just focusing on one character to make that the best possible character we can. We decided to scan Melina, our actress, and so, we had a real world reference we could always look at side by side. Anything that looked slightly wrong, we could address.

In my view, the uncanny valley — when you see a character that falls in the uncanny valley, it’s because something’s wrong. Those things that are wrong can be fixed. The fact that we could fix — I wouldn’t say we fixed all of the issues, but we fixed enough of them that you believe in the character. If we hadn’t done that, this game would not have worked. It’s so much about Senua and close-ups on her. The whole thing wouldn’t have worked if she looked dead-eyed or creepy. That would have gone very badly, given the subject matter.

So yes, we did put a lot of effort into that, into the facial expressions. Melina put an extraordinary effort into her performance as well. I think it was just focusing on one thing and trying to do it really well that paid off.

Image Credit: Ninja Theory

GamesBeat: Why did you think Melina was the right person for the role?

Antoniades: As you probably know, she was our video editor. She was in our office. She’s a very expressive character in the office, a natural mimic and a natural comedian. I think that’s also a good sign that she can act. But she’s freely admitted that she’s experienced mental health issues in the past. I don’t mean — she said it was OK to mention that she’s had some severe issues. I felt like she could go there, as much as she was comfortable in doing. I think she was quite comfortable, after she got used to it, performing in public. She was quite happy to go to very dark places. I think she found that experience cathartic.

In some ways, she was — in some ways, the role was made for her. We were very lucky to have her. She tried to act, at the start of the process. She tried to act, and it wasn’t working. I asked her to stop acting. You can’t teach someone to act. They just have to be. And so, we made Senua more like her, as opposed to making her be someone she’s not if you understand my meaning. Which perhaps isn’t the best way to do casting, but in this case, it worked.

GamesBeat: I also thought the voices were very well done. How do you function with all these people talking in your head?

Antoniades: It’s strange, isn’t it? The main thing I was worried about was just that it would be incredibly annoying to most people. It’s strange how people just internalize those voices very quickly. They start to feel a bit odd when the voices aren’t there, which mirrors what people say to us who hear these kinds of voices. A lot of people that hear voices say they wouldn’t want to be without them. You don’t understand it until you experience it yourself.

GamesBeat: How did you feel about the horror side of things, as far as how far to go with the representations of horror? Or whether you weren’t going far enough?

Antoniades: I spoke to a good friend of mine who had an episode, a psychotic break. He’d describe moments where he was screaming on the ground, thinking he was going to die. He said we should show that. I think what people don’t necessarily understand is that these experiences can be like living nightmares. They can be like being in a horror story in some instances. They can be beautiful as well, liberating and wonderful experiences. But when you see and hear about how horrific it is, I think it helps you empathize.

I wasn’t shy to go there. I think that’s a part of it. And I think any rational person who sees those kinds of visions in that kind of situation would be terrified. It’s interesting how we talk about people with severe mental illness as weak, when any rational, strong-minded person who also sees those things or hears those things or is living that kind of reality would act just like that. It’s a different way of looking at it, flipping it.

The truth is, no matter what we do, we can only touch on the experiences. However horrific we make some of these moments and scenes in Hellblade, it’s nothing like the intensity people who actually experience these things go through.

GamesBeat: I thought the scariest moment was when I was moving around in the dark, trying to get away from the creatures there. I kept thinking there would be a jump scare somewhere, and it didn’t happen. It was almost entirely within my control. If I avoided those creatures, then I succeeded.

Antoniades: But it’s the tension that’s horrible, right?

GamesBeat: Was that something you heard a lot, that the anticipation was scarier than the actual images sometimes?

Antoniades: Absolutely. Some people describe their experience as like — sinister? That’s what stuck with me. This idea that the world has turned sinister around them. The TV starts to send them messages or when the phone rings, they know it will be terrible news. There’s this constant state of anxiety and dread. It’s less about the monster popping up and scaring you. We didn’t really think of this as a horror game at all.

GamesBeat: What were you trying to communicate in the ending?

Antoniades: I don’t want to — I have a very specific logic behind the ending in mind. But it is open to interpretation as well, so I don’t want to give a specific interpretation that will spoil it for other people. What I will say is that — there’s a recurring theme of dying within yourself and being reborn.

I think that relates to people I’ve talked to who’ve come up through this experience. They’ve come out the other side. You don’t hear about this much, but a lot of people who have severe psychotic breaks, they recover, many of them, with help. They come out of it transformed. They come out feeling like they have reconstructed their reality to such an extent that some people give themselves a new name. They talk about their old self in the third person.

There’s this concept of the death of an old reality and the birth of a new one that’s a recurring theme within the game. But at the end, the voices are still there. The visions are still there. The symptoms are not going away. But her understanding of her reality has changed, and so she’s able to — she remembered her mother saying, “Every day is a new story.” The implication of “there’s another story to tell” means there’s going to be a tomorrow.

GamesBeat: I guess this is where the metaphor seems to pay off? You’re conquering your demons or emerging from hell.

Antoniades: This is all spoiler territory, but the darkness came from an idea her father gave her, that she was cursed. And she’s let go of that idea, of the darkness. That doesn’t change the fact that Dillion is dead, that she hears voices that are always going to be there, that she sees visions that are always going to be there. But she can let go of the suffering caused by the idea that it was her fault.

The important thing that some people have gotten wrong, and I don’t know why they’ve interpreted it that way, is that she’s somehow cured at the end. She’s certainly not cured in the sense that her psychosis is gone.

GamesBeat: Hela, the goddess, does she represent something in particular? Was she just one of the last obstacles in Senua’s way, or does she mean something more?

Antoniades: Hela is the Norse goddess who was half flesh, half black. Her mother was burnt at the stake, and she was half burnt, hence the black ash. From her has emerged the darkness. She’s conflated a lot of the mythology of the Norsemen with memories she’s had. The concept of the darkness is wrapped up in that.

There are visual metaphors in the game. It’s not quite — I think one thing I learned with the way people perceive the world is they make a lot of associations. A lot of things are linked. This is something that Paul could describe much better than I can, but you see signs everywhere. You link things that seem to be disparate in meaningful ways. There’s a lot of symbolism throughout the game that’s linked in some ways. But it’s never so clear that you can go, “Aha, that’s definitely it.” It’s lots of associations. It feels like you’re just on the edge of solving the puzzle, but it’s not quite nice and neat and bow-tied.

There is meaning behind why Hela looks the way she does, what she represents, why the ending has the concept of death and rebirth. I think it’s more interesting if that stuff is left up to interpretation. There is a logic behind it.

Image Credit: Ninja Theory

GamesBeat: The realizations that Senua makes at the end, they include recognizing that Dillion is gone. He can’t be brought back. And she isn’t cursed, as her father had said.

Antoniades: Right. It’s an idea, a reality that her father put in her head. Dillion nearly broke that idea. He had a competing idea, which was that she’s not cursed, not at fault. When Dillion died, her father’s reality took over and dominated her. It took this journey to come back to Dillion’s reality, if you like, and reject her father’s reality.

GamesBeat: I did wonder why she had to have such a cruel father and why Dillion had to die, but it seems like these are the things that turned her psychosis into something negative.

Antoniades: Yeah, yeah. Her father was — I see him as someone who — he was a Druid, and the Druids had a lot of power in Celtic society, more so than kings. He’s a seat of power. What he says goes. He speaks for the gods. This is another version of reality that he’s living in. I think the game does touch on these ideas of people’s versions of reality and how they affect other people’s lives. He thought he was speaking for the gods, that he had to maintain control over her, that he had to banish this curse. It’s not necessarily that — everything he did to her was evil, for sure, but he had his own internal logic behind it all.

GamesBeat: The story in some ways a little confusing, I think because it was told in flashbacks. I had trouble placing — oh, this is why she’s gone off the edge.

Antoniades: That was on purpose. When we remember the past, we don’t remember it as a nice, neat, linear story. We remember moments and fragments of our past. The structure — I felt like making everything neat and tidy and linear in terms of the story didn’t matter. These are the events that shaped her life. There are moments that are out of order in terms of time that I was worried about, but most people’s experience is that it doesn’t matter what order they were in, unless they want to work it out. You can work it out. But these are the moments that shaped her character. Although it might be confusing, you get the picture, I think.

GamesBeat: Did you mean something in particular by “other adventures?” Do you imagine a sequel to this?

Antoniades: Just before she says that, she remembers the voice of her mother or hears the voice of her mother saying, “Remember what it was like to be a child, where every day is a new story.” And so, she remembers that and then says, “Come with us, there’s another story to tell,” meaning there’s another day to live. It was more about that. I must admit it does come across like, “Oh, here comes the DLC,” but that’s definitely not what the intention was. I mean, I don’t know what’s going to come next, honestly. I do not know.

Image Credit: Ninja Theory

GamesBeat: How did you settle on the sword-fighting style, by the way, where you banish the same demons over and over? Did they also represent something in some way, the pattern of fighting those characters?

Antoniades: Hmm. I don’t know. The main thrust of the combat was to make it feel dangerous. Even though you can dispatch lots of enemies quite easily, the feeling of peril always had to be there. The fact that they look more demonic than Vikings — I imagine them kind of like — what was that movie? A British movie? The Wicker Man, where everyone has animal masks and it’s all quite pagan. I imagine something paganistic like that.

But for it to be never sure whether what she’s seeing is a real person or an exaggeration of a real person — the idea is that they are as she sees them in her mind. They’re bigger than a normal person. They’re more demonic, like the guy with the fire head. They’re more demonic than they would be in “real life,” if you like. And then, the final battle should feel a bit like a fever dream, like an endless nightmare.

Some people interpret the demons as all being in her head, and some people say that maybe that’s just how she sees real Vikings. I think either of those is a valid interpretation. I prefer to think of them as real people.

GamesBeat: Has the game sold well for you, though, given your expectations?

Antoniades: It sold better than our expectations. We’re doing one more dev diary where we’ll give out numbers and detail how it’s done. We want the data out there so other developers, if they want to do something similar, they have a data point, hopefully, to help encourage them to do more games like this.

I think it’s almost broken even, or it’s about to break even in the next couple of weeks. I’d have to check. We weren’t expecting to break even for six, eight, nine months on this game. It looks like within three months, it will have broken even and then some. Of course, because we self-published it, it’s the first time we’re getting the bulk of the money back, which is amazing. We own the IP this time. It’s opened up a bunch of doors and possibilities that we just didn’t have until this point. In terms of a model, I’d say it is a success.

Image Credit: Ninja Theory

GamesBeat: So, it turned out that going indie was the right move for this?

Antoniades: Yes, yes, I think it really was. The triple-A publishing model goes in cycles, sort of, but it doesn’t really serve developers like us very well, mid-size developers. A lot of opportunity is out there for developers, but the triple-A model is a difficult one, a dangerous one, where you’re not fully in control of your destiny. As we’ve seen over the last several years, dozens of good developers have disappeared. The only way you can counter that is find another way. This seems to have worked for us.

We’ve documented the whole thing with our dev diaries. We’ve laid out how we’ve done it, and soon, we’ll release the data as well. We’re doing that because we genuinely want games to be as exciting, ambitious, and creative as they used to be — and still are to an extent. But there’s a real danger in losing great studios at an alarming rate when we shouldn’t have to, simply because we don’t know what works and what doesn’t in the digital era.

GamesBeat: Do you feel like there’s anything else in your genre? The one comparison I’ve seen is that it’s like a triple-A Depression Quest.

Antoniades: [Laughs] I think people have had trouble trying to categorize it. They use terms like “walking simulator action game,” “depression tourism,” whatever. I’m just glad that it’s breaking away from the patterns of what you expect from a game. It really was an experiment. We had no idea whether it would work creatively, either. The fact that the intro is eight or nine minutes of not doing anything at all — you make a gray box level where this is going on and everyone looks at you like, “What the hell are we making here?” But in the context of the atmosphere, the story, the immersion, it really does seem to have worked.

I think it helps show that if you focus on the experience, anything can work. We break out of that idea that a game can only work if it’s a 60-second loop of fun repeated over and over again.