Throughout spring of 2020, I, as well as a study partner, wrote a bachelor’s dissertation in social work that focuses on the use of tabletop roleplaying games in therapeutic treatment of individuals with mental illness and autism spectrum disorder. We interviewed six professional practitioners with experience using tabletop roleplaying games therapeutically, and we compared the results previous research that we could find on the subject. The study itself is in Swedish and can be found in full HERE. In this blog post I will summarize in English some of the most important points from the study.
A good mental health is vital for our ability to function as well as our general well-being. On the other hand, a poor mental health can encompass anything from mild to serious forms of anxiety and depression as well as complex psychiatric conditions. Some conditions can affect an individual’s mental well-being in different ways. There is much to indicate that tabletop roleplaying games can be used as a form of play therapy in mental health treatment as well as in treatment of individuals with autism spectrum disorder (ASD). Fantasy and imagination are something that can be used as a tool to support, empower, and guide people towards cognitive, social, and emotional development. Before discussing therapeutic roleplaying in more detail, it is important to also mention symbolic play. This is a vital aspect of children’s development and refers to when they use objects, actions, and ideas in order to represent other objects, actions, and ideas. Through symbolic play, imagination becomes a tool that helps children better face the real world, such as through improved language comprehension and understanding of how to act in different situations. By using different forms of play therapies, a therapist can aid children in their development through symbolic play (which has proven effective especially for children with ASD).
A tabletop roleplaying game is a game where a participant pretends to be someone else, but unlike a child’s imaginative play, these games follow an established structure and are presented through conversation and random chance, such as through dice rolls. The participants in these games create a shared narrative where the GM is the director who presents a number of fictional situations within an overarching narrative, and the players portray characters who become their avatars within this narrative. These characters have their own strengths, weaknesses, and traits which are often represented by numerical values that affect the outcome of the dice rolls used to establish whether various actions in the game are successful. People who play these types of games often do so in order to explore their imaginations and share stories, or they do so to picture a different world with different possibilities. These games allow people to, through their own imagination, become heroes, villains, or just someone else. While this is much more structured and intentional than ordinary symbolic play, the roleplaying activity has parallels with symbolic play in the way imagination is an important fact that contributes to real development.
The amount of research that delves into therapeutic applications of tabletop roleplaying games are limited and for that reason we also looked at other research related to fantasy and roleplaying games. One possible reason for the limited research is that tabletop roleplaying is a niche hobby that still is not widely spread, and more research has been put into aspects such as social psychology than direct treatment. Tabletop roleplaying games are highly psychological in the way that participants accept and embrace fictional identities, fictional goals, and fictional realities. The fiction itself, and its effects, have some parallels to the benefits of symbolic play. Through their imagination, children develop their thinking by exploring lines, thoughts, ideas, and their own selves. This can be translated to adults as well, but then metaphors can more commonly replace playful imagination. A child can picture a wooden block as a train, but the adult can picture personal concepts such as identity and self-acceptance. Even though the things a young child and an older adult can get out of their imaginations can be different from each other, the imagination itself is powerful for both. But even play can be powerful for both, since play and creativity can give both children and adults ways to express uncomfortable thoughts and feelings in a way that lets them keep at a safe distance from the challenges of the real world while at the same time face those challenges through metaphor.
Play therapies can be tailor-made towards individual characteristics and behaviors, and this becomes especially true when talking about tabletop roleplaying games. For example, a therapeutic GM can give feedback to an individual and their character’s actions which can help them towards personal growth. In addition, the collaborative and improvised narrative that make up these games can also lead towards social, creative, and intellectual development as well as increased leadership skills. When you put your focus on the story and the roleplay, the game can enforce collaboration, creative thinking, social interaction as well as the individual’s ability to act, orate, and problem solve. The narrative itself can be of importance as well since it can represent a hero’s journey where different difficulties and obstacles are overcome in order to contribute to a personal change or growth. While older research during the Satanic Panic often defined roleplayers as socially isolated, more recent research indicate that the opposite is often true; roleplaying games can encourage friendship maintenance and pro-social feelings such as love, empathy, and respect.
When it comes to personal development, research show that the relationship between an individual and their character can lead to both positives and negatives. Through the act of roleplaying, a person’s fictional character can sometimes blend into their real selves in a way. While this can often lead to positive experiences where players feel like they create real memories together of fictional events, it can also lead to negative experiences causing real emotional or traumatic reactions. There is a line in between the player and their character where there can be an emotional overlap.
The Client Group
The informants in the bachelor’s study have used therapeutic roleplaying games in treatment of veterans, addicts, people with serious mental health difficulties and diagnoses such as depression, schizophrenia, and affective disorders. They have used the method to empower young girls, teach them to find their voices, to collaborate with others, and to have fun with games. They have used the method in treatment of children with developmental disorders, behavioral difficulties, or who have suffered mental, physical, or sexual abuse. Many clients with mental health difficulties have ASD as well, and several of them have been bullied, have no friends, and feel very isolated. According to the informants, clients who are children or youth should preferably be placed in groups of similar developmental level. While it is possible to have younger kids with older teens successfully, having separate groups for more mature teens may be helpful if you want to explore more mature themes in the game. However, there can also be therapeutic value in diversity and peer-learning where, for example, you can have one person with success strategies for their anxiety which could also be success strategies for another player’s depression. The fact that players help and learn from each other also means that the therapeutic GM does not have to be the one barking out all the wisdom. While it is generally a positive thing that client groups have diverse personalities and backgrounds, there are exceptions. For example, a homogenous group is often necessary to provide a safe environment when the client group consists of, for example, girls who have suffered sexual trauma.
In general, the most optimal client group has four players in it, but some practitioners have groups of six players instead – often for financial reasons. If there are too many players, the spotlight cannot shift fast enough, and being able to give the spotlight to individual players is valuable for their therapeutic payload. It is more difficult to get groups together for adults since they tend to have jobs and expectations limiting their ability to meet. Many adults also tend to question if a play therapy would work on them, and tabletop roleplaying games are a form of play therapy after all. In summary, not everyone is a good fit for this type of therapy and some simply are not interested in it.
Apart from the therapist and the clients, it is common to have an assisting facilitator in the room that can play together with the clients and who understands the therapeutic value and how different situations should be approached. This facilitator can help reach the clients on a personal level through play or help guide them towards therapeutic effect. Sometimes they can even help the therapist by being a game master or by providing support to individual clients.
The Tabletop Roleplaying Game
Genre is generally described as an important aspect in order to connect the game to clients’ interests. If a client does not like the fantasy genre, then it can be hard to capture their interest using Dungeons & Dragons. Some informants have started using the game Kids on Bikes in treatment of ASD. What makes this game good is that it focuses on narrative and have a built-in feature that helps players who fail their actions to succeed on upcoming ones. This kind of feature is a good way to get clients to dare taking more risks in the game. While D&D is the most used game, most informants agree that the game itself is less important than the fact that there is a game system to act as a framework for the experience. For kids and youth with ASD, this framework provides safety, but it can also be too complicated at times. But even if the rules are too complex for some individuals, it is important that the rules are there, and that the GM can use them throughout the sessions in order to provide the structure that is so important especially for players with ASD. The rules must be there to enable play, but if there is too much focus on them, it is easy to lose out on the play. The goal is to have the game’s rules fade into the background so that the story can surface. It is important that the therapist can break the rules in order to highlight what is fun and dramatic in the story, but it is also important that the therapeutic GM themselves is familiar with the rules and knows why and how they can be broken. The primary goal of therapeutic roleplaying is to have the participants sit together in a circle and tell stories in order to build community. The rules provide a structured way of reaching that goal.
The Therapeutic Structure
Therapeutic roleplaying games usually consist of about eight to ten sessions of two hours each. These are initiated by a Session 0 where the group prepares for the coming adventure. Here, the therapist explains the rules, asks the clients what kind of game they want, and they make characters together. It is common among some practitioners to use questionnaires asking the clients about their presenting problems as well as their interests in order to be able to tailor the narrative towards them. For example, the GM asks the players what kind of game they want to have, what kind of game they do not want to have, and what may be some subject matters best to avoid. Since some players may struggle with trauma, it is important to value their safety at the table. The GM should also ask the players what they want to focus on in the game, such as their distress tolerance or impulsivity.
Most sessions consist of a check-in before the roleplay followed by a check-out before the session’s over. Adult players may need shorter check-ins and longer check-outs where they discuss what they learned from the game. Players who have suffered trauma may prefer to have less focus on structured check-ins and instead pause the game more often for check-ins throughout. It is common to do a fifteen minute check-in at the beginning of the session to see how everyone is doing, and then another fifteen minute of housekeeping at the end of the session. In between is about ninety minutes of roleplay.
In treatment of ASD, the therapist places more importance in a decided structure because their clients can be very focused or distracted by their own feelings which affects their capacity to connect, problem solve, and have fun. For them, a predetermined structure that does not change from session to session is comforting. It is also comforting if the check-in and check-out questions are presented in the same way every session. Some ASD groups use a talking object that dictates who gets to speak and that everyone else must listen. This helps them train their social endurance as well as their ability to share and speak before a group.
After the check-in, it is time for the actual roleplaying adventure. It is common that the first scene that the therapeutic GM introduces to the group is a social environment where people meet, and where the players can interact with each other in game. If the client group consists of kids or addicts, the traditional inn could be replaced with something like a soup kitchen – so that no alcohol is present. The therapist describes the environment of the scene, who are there and what is happening. The players may then describe what their characters do in this scene. The GM can then let them interact a bit before introducing an event that will spur a reaction – such as having bandits show up.
If conflicts arise between players, it is important that the therapist can take control over the situation. That is a good time to pause the game and note the undesirable behavior that has been observed as well as help the clients resolve the conflict. If someone gets frustrated and leaves the room, it is important to normalize that they have the right to do so. In that case, the assisting facilitator can help in either taking care of the individual who stormed out or the rest of the group, depending on the need.
Treatment Focus for Mental Illness
The focus of therapeutic roleplaying games is not to treat or cure a specific diagnosis. Instead, the therapist needs to identify the individual symptoms or problems the client wants to deal with and focus on them. For example, someone who wants to focus on their impulsivity may want to make a character that is also impulsive in order to observe the consequences of their character’s actions. A client with low self-esteem may want to make a character with a high self-esteem in order to experience how that feels and how others react to it. A therapeutic GM plans sessions tailor-made for the clients’ individual symptoms or problems in order to aid the clients’ personal growth. If a client, for example, expresses that they want to be able to trust people either more or less, the GM forms situations in the game where the client’s ability to trust or not trust cause in game consequences that can translate to real life realizations. The therapist and the client can then reflect upon this during the check-out.
When it comes to trauma clients, it is important to not speak about the trauma or situations that can be triggering. Instead, the therapeutic GM focuses on individual trauma symptoms and how the client is affected by those today. If the client is a child, then safety is an especially important aspect of the treatment focus.
Treatment Focus for Autism Spectrum Disorder
When treating autism spectrum disorder, the focus is on potential; to get individuals who are always told that they are bad or wrong to instead hear that they can be heroes, that they can do what they want, that they can take control over their lives. The treatment focus is about letting clients face situations they could face in real life. Through tabletop roleplaying, they get the opportunity to practice these situations in a context without negative consequences. The empowering girl groups that one informant has have both clients with ASD and those with mental illness. In those groups, much of the treatment focus is on empowerment and aspiring attributes where the clients get to train themselves in finding strength where they feel weak.
A fundamental principle in the treatment of ASD is something called narrative transference. This refers to the thoughts, feelings, and compulsions that clients project on their characters, as well as how this can be utilized to help the client towards insight, development, and change. The therapist uses the client’s character in order to find ways to transfer development to the client themselves. This can be done by looking at the relationship the client has with their character’s behaviors and actions, and then acknowledge how to best help the client feel safe and grow. One informant points out that much of this process takes place within relational play where the therapist tries to get the clients to connect to their affects, like their expressions and body language. Many clients with ASD have a compromised capacity of self-regulation which means that situations and impressions can have a tremendous impact on their mental state. Through relational play, the client is trained in facing both emotional highs and lows while they are keeping themselves regulated. How effective this is has a lot to do with the therapist’s intuition and resonance with their clients.
Fantasy as a Tool
Unlike traditional discussion therapy and other forms of play therapies where you symbolically play out ideas, the player can, using their character, reach a level of distance between themselves and the subject matter. It is common especially for adult clients to say things like “I don’t think this will work on me because of X, Y, Z” which could be anything from them not being comfortable sharing, them not trusting others, or them not being comfortable with therapy at all. If they still participate in the session, the therapeutic GM gets to meet them within the game and facilitate so that they can project on their character. When the client says that they want to distance themselves from their character, they are free to distance themselves – but sometimes the GM can challenge the client with check-in questions such as “is it you or your character that’s reacting right now?”
Therapeutic roleplaying games are different from other group therapies in that the development occurs discreetly through play rather than through direct confrontation – this is something many clients feel is positive. The roleplaying game can, in a sense, “sneak in” the therapeutic effect. And because it is based on a game, it is something clients can appreciate and enjoy without it feeling like work. Fantasy and metaphors are effective tools to let players associate with different ideas and concepts. Through a roleplaying adventure, the player gets to explore themes they would not otherwise necessarily recognize as connected to their own psychosocial difficulties. One informant in the study explained how a client group’s characters were all turned into werewolves. The adventure was first to find a cure but then ended up being about learning to control their werewolves. Using the fantasy as a tool to guide the clients is equivalent to symbolic play in a way; the fantasy becomes a metaphor for reality. The werewolf is a metaphor for anger – anger is real. One way of measuring a player’s development is by comparing the character they create at the beginning of the therapeutic game with the character they create a few months in. If the player feels that they no longer gain a therapeutic value by continuing to play the same character, it could be a sign that there has been personal growth.
Roleplaying games offer social training. Unlike the real world where everything happens so fast, it is possible to slow down a roleplaying game in order to create the time and space needed to reflect over what’s happening and test different approaches. A roleplaying game offers an endless amount of stimuli to interact with and many more opportunities for different interactions than what a person can realistically experience in real life. Many clients in need of social training are often people who are socially isolated in different ways. Many of them spend most of their time at home in front of a screen. Here they get the opportunity to play while the screen is removed and replaced with a table and others to interact with. It is common that clients who start out shy end up being diplomats and leaders for their groups. The treatment can counteract social isolation and encourage connection with others, both for clients with mental health difficulties and for clients with ASD. The group has a huge impact on the treatment. It is not uncommon for some clients to keep in touch with each other outside of sessions as well. People who were stigmatized and isolated find, through tabletop roleplaying, connections that they choose to hold on to.
The informants who work primarily with children and youth with ASD point out that people are the best they can be when they feel safe and have fun. The treatment helps children and youth, who have previously been defined by their disabilities or challenges, to reframe their own self-image. Many children and youth with behavioral issues are used to hearing things like “how do we get you to change?” when they should be hearing things like “what are you good at and what do you like?” The tabletop roleplaying games can through the narrative naturally increase prosocial attitudes. Many youths with ASD do not have a reason to want to be social, but the game can activate that will within them.
One informant let war veterans fill in a questionnaire after every session to be able to follow their growth over time. The results showed an increased ability to interact emotionally, to problem solve, to experience empathy as well as control negative emotions like aggression.
A Fun Alternative
A positive with therapeutic roleplaying games is that it is seen as a fun alternative for those who feel scared, degraded, or bored with traditional therapies. Many therapies feel like work which can be frustrating for many clients. The roleplaying games do not only bring play to the table, but also the positives of play. Through play, clients get to train their creativity, build self-confidence, see things from others’ perspective, and connect with others. Even the act of play itself is a skill they get to practice.
For many with psychosocial difficulties, roleplaying games can be better as a complementing therapy that tackles certain symptoms and empowering the individual socially and emotionally. For example, a client may need individual therapy for their trauma or addiction. The treatment is also reported to have negative consequences on individuals who have a hard time distinguishing fantasy from reality. When there is magic and dangers in the game, it can be unhelpful to let that blend into the individual’s perceptions. Another risk is the possibility that clients could encounter stimuli that would trigger their trauma. Even if Session Zero and check-ins are used to reduce this risk, it cannot be eliminated completely. Some clients get extremely uncomfortable by depictions of violence, for example, even if the violence is fictional. Some individuals are seen as unfit for other reasons, such as by the fact that they could simply not be interested in roleplaying games at all, or they are interested in it as a hobby but not as a therapy. It is a positive that tabletop roleplaying games are a fun alternative to therapy, but if the clients get hung up on the fact that it is fun, they risk losing out on therapeutic payload.
It is described how tabletop roleplaying games have been used successfully in family therapy, drama therapy, psychodynamic treatment, and behavioral treatment. The method is applicable on many diagnoses and alongside many theoretical models. However, the most important aspect of the treatment is that the therapist is competent both as a group therapist and as a GM. They need to be familiar with a roleplaying game and be comfortable playing it. It is also important that the therapist has some level of improvisational skills and an ability to share of themselves.
In treatment of ASD, a poor structure could have negative consequences. A therapeutic GM who does not resonate with their clients can cause harm – they can harm their own relationship with the client group, but they can also harm the therapeutic effects and the clients’ growth. Just like how structure is important for clients with ASD, the group dynamic is important for therapeutic payload. If a group consists of individuals at varying developmental stages, the treatment could be harmful for those at lower developmental stages. This is not a universal truth, but it is a risk that needs to be kept in mind when a therapist forms their group.
In summary, tabletop roleplaying games let clients experience fictional situations presented by a therapist where the goal is to awaken real emotions and subjects for reflection. In treatment of ASD, it is important with a solid structure while treatment of mental illness focuses more on the individual symptoms. One red line is that the method first of all provides social training in a safe environment where fantasy becomes an effective tool for projecting thoughts and ideas. The game also provides good opportunities for personal growth but can be limited in its applicability: individual therapy may be recommended for some symptoms that therapeutic roleplaying cannot reach. This type of treatment also requires other things from the therapist than simply experience in group therapy; the games need the therapist to be creative enough to construct a narrative, to roleplay alongside the clients, and to share of themselves.
We were two authors who made this study, and I was the one who had some level of familiarity with the subject matter beforehand. Since I have freelanced as an RPG writer, I also had some professional contacts with insight in the field. Even though the study was in Swedish I knew that we had to interview American practitioners because that is where the treatment method exists and flourishes. A literature study would not have been possible because of how niche the subject matter is, and because existing research is so limited. We also understood that the number of informants would be important for the study’s reliability. We were happy to find out that all informants we interviewed had experience treating both mental illness and ASD – there is also often an overlap between the two. Only three informants had experience with adult clients, which makes the reliability of information related to adult clients lower than that of kids and youth.
There are many different types of roleplaying games with different rulesets and different genres, but the primary importance is in the structure surrounding the session itself – Session Zero, check-ins, and check-outs. These are essential structural parts so that the therapist can connect to the group. In treatment of ASD, more weight is put on the structure and it is a positive if the check-ins and check-outs look the same for every session. For mental illness, more weight is put on reflection and individual process in relation to the client’s thoughts and realizations.
There is a lot that indicates that fantasy is an effective tool, and the way tabletop roleplaying games are structured gives room for a controlled distance between the client, the character, and the situation. This can, among other things, let the client group approach certain subject matters in a safe environment, and a lot of the treatment focus lies in identifying moments that can be used for personal growth. Only the social aspect alone is a common red thread for both mental illness and ASD. However, it is important to highlight that the method itself should not replace more evidence-based methods, especially when it comes to more serious mental illnesses, but there are good indications that this could be an excellent method for highlighting and reflecting over individual attitudes, and to provide broad social training and personal growth.
Art by EGinvent / Adobe Stock