Jackson Ryan/CNET

The Xbox studio battling mental illness with video games and neuroscience

The Insight Project is Ninja Theory's ambitious plan to combine neuroscience, biometric sensors and game design to treat mental illness.

Senua sees things that aren't really there. 

Villages burning to the ground. Norse runes bleeding color. Lumbering giants wearing skull-masks and swinging heavy blades. Sometimes, she hears voices whispering in her ears. Her hallucinations are frightening and alien, but to her, they feel as real as the ground she walks on.
But they aren't real. And neither is Senua. She is a character in a video game, a young Celtic warrior created by Cambridge, England, development studio Ninja Theory. Four years ago Tameem Antoniades, chief creative director at Ninja Theory, set out to make a video game that would put the player in the shoes of someone suffering from severe mental illness. The result was Hellblade: Senua's Sacrifice.
To ensure the game depicted psychosis candidly and empathically, Antoniades and his team collaborated with Cambridge neuroscientist Paul Fletcher, an expert in the field, and asked those living with mental illness to share their experiences. The depiction earned the team five BAFTAs and an award from the Royal College of Psychiatrists, the UK's leading organization on psychiatry.
"The fact that we were invited to so many science conferences … kind of made me realize that the work we've done was quite significant in some way," he says. "And it's significant because we helped represent something that was very difficult to represent."


Hellblade: Senua's Sacrifice is unrelenting but players and scientists lauded its portrayal of psychosis.

Jackson Ryan

Hellblade wasn't the first game to confront the realities of mental illness, but the response showed what was possible: Video games can change attitudes toward mental health and they are uniquely positioned to explore the fundamental workings of the brain.
With that in mind, Ninja Theory and Fletcher are embarking on a new venture that will take everything they've learned in game development and psychiatry to create an entirely new experience.
It's called The Insight Project.

"We want to create games that can change people's lives," says Antoniades.

Making the invisible, visible

But The Insight Project isn't necessarily a video game. It's not a brand-new intellectual property and it's not a sequel to Hellblade. It's an evolution of the collaboration between Ninja Theory and Fletcher, building on five years of research and a growing scientific movement in neuroscience.
It's an ambitious plan to use video games to create new therapies for mental health disorders using biometric sensors to capture physiological data and lifelike simulated avatars and environments.

Tying together cutting-edge clinical neuroscience, game design and emerging technologies, Ninja Theory has developed a prototype monitoring kit that measures various physical outputs such as heart rate, eye movement and respiration. It's already being tested on pilot subjects, including Fletcher, during physical and psychological challenges. If the data looks good, the team will move onto its first ethically approved scientific study.
The project feels more science than video game right now, but the potential is huge. Fletcher explains how psychiatrists and neuroscientists are beginning to appreciate and explore the links between mental distress, a person's physical state and the environment they're in. Using the monitoring kit could pull apart this relationship, opening up a new opportunity for Ninja Theory.

As it stands, the team wants to create video games to show the many different states of mind, whether that be anxiety, fear, psychosis or other forms of mental distress. This would give patients "insight" into their symptoms and could help them manage their condition, explains Antoniades.
In other words, the Insight Project isn't about kill/death spreads, high scores or leader boards. The goal is to help people overcome their mental distress.
"If you can see what's happening inside your mind, then you can remove yourself from the symptoms and view it in a new light," Antoniades says.
It may be a science-first endeavor, but Antoniades says that eventually he wants to produce a compelling, high-end game, rather than something that feels like it should be played in a laboratory.
"If we can turn it into a mainstream game that people want to play, then it has the potential to reach an audience that goes well beyond that small section of the population that needs and seeks therapy," he says.


By using biometric sensors like BioRadio, Ninja Theory can study physiological signals from players.

Ninja Theory

The next level

After Hellblade's release, Ninja Theory and Fletcher noticed there was a subtle shift in the conversation around mental health. Players flooded the team -- and social media -- with praise. Some saw it as a way to express their suffering to family and friends. Others celebrated the game for its depiction of psychosis.
"One of the things that just really blew me away after Hellblade was released was to see a conversation opening up on the internet about its representation of mental illness," says Fletcher.
Increased representation of mental illness in popular culture is helping dispel some of its stigma. The percentage of American adults with mental health challenges has remained stable for the last eight years, but youth cases are on the rise.
There are two main treatment options for mental distress: medication and therapy. Fletcher explains that drugs treat the symptoms of various mental illnesses, typically by blocking signals in the brain, but they do come with a host of unpleasant side effects. On the other hand, psychotherapy, in which trained therapists help patients explore anxieties and fears, is accepted as one of the gold standards -- but it isn't a cure-all, and many patients fail to respond. The diversity of mental health issues can make it difficult to predict what will work for any given patient.
That creates an obvious need to continue to explore new and innovative treatment options. Video games have been a part of that conversation for decades, and contrary to the negative headlines about Fortnite , screen time and violence, there are mountains of anecdotal evidence suggesting players can improve their mental health via play. Serious video games and gamified apps are slowly filtering into mainstream consciousness, and a handful of clinical trials are examining their use in conditions like psychosis and schizophrenia.
Fletcher thinks more personalized treatments using game design principles could take treatment options to the next level. It comes back to the idea of making the invisible visible.
"What I think is missing is a full grasp of the different forms of psychotic experience," he says. "We think that allowing a person to more deeply convey their own experience might facilitate this."


The Insight Project draws on the clinical knowledge of Paul Fletcher (left) and the game development knowledge of Ninja Theory creative director Tameem Antoniades (right).

Ninja Theory

Your brain on video games

Scientists readily appreciate how malleable and adaptable the brain is. Over the course of a lifetime, it can form new connections, learn new skills and even repair itself after significant injury. As our conduit for perceiving and understanding reality, the brain registers every experience to some degree. Video games, then, can absolutely change the brain.
"The interesting question is, of course, to what intensity does change happen, and in what ways," says Steven Conway, lecturer on games and interactivity at Swinburne University in Australia. "The explicit feedback loops provided in games, potentially, can impact the brain's development at a higher intensity than other phenomena, since it's supercharging learning."
Several projects have already shown video games can help the brain recover control over the body by promoting physical therapy. They help rehabilitation, encouraging the brain to form new connections or strengthen weakened ones.
At Mount Sinai Hospital in New York, a team of quadriplegic esports athletes are using video games to augment their rehabilitation. Similarly, a lab at Johns Hopkins School of Medicine released a game specifically designed to help stroke patients regain movement in weakened limbs. In it, the patients control a dolphin as it collects fish and avoids sharks. Preliminary results show it may be more beneficial than traditional stroke therapy.
But how effective might video games be for promoting mental wellbeing?
"There's definitely a role for video games in helping mental health interventions create more engaging experiences and also enabling deeper types of learning," says Vanessa Cheng, a researcher studying gamified mental health apps at the University of Sydney's Brain and Mind Institute. There are already some success stories using game design principles.
A team of researchers at King's College in London has been pioneering a digital treatment regime for psychosis patients known as avatar therapy. The technique allows a patient to speak with an avatar that represents the at times hostile voices they hear. Over the course of therapy, the avatar, voiced by a trained therapist, becomes less aggressive toward the patient, and this allows them to gain power over the voices. Initial results, from a randomized controlled trial, show it may be more effective than counseling.

A lifelike avatar on a screen, for use in mental health treatments.

Creating lifelike avatars could lead to new treatment options for mental illness.

Ninja Theory

Antoniades lets on that there's another project at Ninja Theory which could supercharge this type of therapy. He explains how a second team within the studio is building the most realistic avatar and most realistic environment "ever seen." It's easy to see how the tech could be incorporated into a similar scientific study, placing a patient face-to-face with their illness.
But what is actually happening in the brain physiologically during psychosis? Fletcher concedes that the short answer is "we don't know," and within the scientific community opinion is divided. This is where the Insight Project really hopes to excel. Can it untangle the host of physical and biological signals that relate to anxiety or mental illness? How do these signals change during game play? Can they be controlled?
Fletcher says these kinds of questions can be answered using the work already done at Ninja Theory to marry biophysical measures and game environments.
Cheng notes that clinicians are still unsure about technology and integrating apps in their work, which means they could be reluctant to use video games as therapy. The Insight Project won't become the treatment option for mental distress, but part of a toolkit therapists can deploy to better help patients.
"I think it's safe to say that video games and other game-related therapies will never replace traditional therapies and medication," Cheng says, noting that "for people who may not be well served by traditional treatment methods, games can certainly complement treatments."

A hand holding wires with sensors for monitoring physiological responses

Ninja Theory is experimenting with various sensors to probe the physical responses to mental distress. 

Ninja Theory

A problem of our times

The Insight Project is not a game you'll find on your Xbox next year. It's unlikely you'll see it there in 2021, either. The unveiling is, more than anything, the beginning of a multiyear research project.
"You can't solve this problem with one product. It's like trying to solve climate change," says Antoniades. "Our interest in this project is to find a new approach to a problem of our times."
It's interesting to evaluate Insight in context of Ninja Theory's acquisition by Microsoft's Xbox Game Studios in 2018. In an interview with gamesindustry.biz last year, Matt Booty, Xbox Game Studios head, discussed the importance of buying Ninja Theory, detailing how critical the studio would be in developing content for Microsoft's Netflix-like video game subscription service, Game Pass.

How, if at all, the Insight Project might fit into a service like Game Pass is currently unknown (Booty declined a request for comment), but being bought by Microsoft has clearly helped the team embrace its new mission. Antoniades says Ninja Theory is "no longer focused on survival" and can pick the projects it finds interesting.
"For me, [the Insight Project is] the most interesting project we're doing," says Antoniades. The pressure to deliver the next best-selling video game is off. Ninja Theory won't be blazing ahead in an effort to create something that can sit in the Microsoft storefront.
"We have to approach it very cautiously and carefully. We have to make sure the ethics are right, the privacy guidelines are right [and] the science is right," he says.
In many ways, they have to -- the project will evaluate sensitive patient data on mental health. Real people will undergo testing. Ethics committees will need to scrutinize any proposed experiments, data will have to be secure and patient privacy will need to be at the top of the list of priorities. That might mean the Insight Project will move slowly, but that approach has worked for Ninja Theory and Fletcher so far.
In essence, The Insight Project is a culmination of an idea that sprouted five years ago, as Antoniades tried to make sense of his friend's psychotic break. He approached Fletcher for help. The pair listened as patients shared their stories. Then, with a team of just 20, Antoniades built Hellblade: Senua's Sacrifice. It made the invisible visible. For many, it changed how mental illness was perceived.
Now for the next step: Changing people's lives.

Originally published 6 a.m. PT