Dungeons and Dragons in Therapy
Does it work?
Every now and again, when I think of doing some clinical work on the side of my academic job, I consider doing “geek therapy” using Dungeons and Dragons (D&D). D&D, for the sadly uninitiated1, is a role-playing game in which players create characters who they play through various adventurers in a medieval/Renaissance themed world, guided by a Dungeon Master (DM).
Given this is a pretty open and free-flowing system, for decades therapists have observed it could be used to put players in scenarios that help them develop social skills, assertiveness, and cooperation and reduce their stress. Thus, some clinicians offer therapy based on D&D for, say, youth who may benefit from increased mood and social skills, but don’t much care for traditional therapy. Of course, it’s a fair question whether such an approach actually works.
A new study, led by Joël Billieux at University of Lausanne in Switzerland suggests it just might. Participants were 18 French-speaking individuals who scored high on social anxiety and a measure of “problematic gaming” (a somewhat controversial diagnosis, but that’s not super critical for this discussion)2.
Participants played 10 sessions of D&D. These were taken from preexisting D&D modules (stories) but were designed specifically around social encounters, traps and puzzles rather than raw combat, presumably as these allowed for social interactions among players and cooperative problem solving. The challenges got harder over time, with the final sessions giving the players the opportunity to take on the DM role for a time.
The study used multiple case design formats (essentially tracking improvements of the players over time), and found reductions in social anxiety, problematic gaming, and loneliness, but no improvements in assertiveness or self-concept. Overall, that’s a pretty good outcome and I also appreciate where the authors were honest about where things didn’t improve. The study was a registered report, which increases my confidence in their findings.
There are obvious limitations which bear noting. This was an exploratory study, not a randomized controlled trial, so our excitement must be tempered. The sample size was very small (in part owing to the time commitment of running D&D sessions one imagines). As noted, “problematic gaming” is a controversial diagnostic category, but I think we can say at least it’s a proxy for other mental health issues.
So, overall, I think this is an interesting “proof of concept” and would love to see the authors move this forward to a randomized controlled trial.
Traditional therapy isn’t for everyone. Finding ways of helping populations who are disinclined to seek therapy via traditional routes is an excellent undertaking3. Using games, including D&D, may be an excellent way to reach populations disinclined to recline on the proverbial couch and disclose their inner hopes, dreams and disappointments. But such approaches must also be subject to scientific scrutiny and it’s good to see some of this being undertaken.
One of the questions I’ve always lingered over was how to make D&D therapeutic and I appreciated the guideposts here. I may always be too lazy to do D&D therapy (laziness is a roadblock to a lot of things for me), but I’m glad some folks are working to make this approach science based.
Those who don’t play D&D live truly benighted lives.
These controversies are probably worth of a separate post. The gist, though, is clinicians and researchers disagree about whether this is a “real” condition, or merely a symptom of other mental health issues such as depression, ADHD, anxiety, etc. I’d say the evidence is pretty mixed. Moreso, though, it’s not clear why so much of the clinical/research apparatus has focused on “gaming” overuse as opposed to all the other things people overdo (in fairness, some folks like Mark Griffiths do make this arguement about everything from dancing to fishing, but mainly get ignored). The sense is that gaming is the focus because of a larger moral panic about vidoe games (and now social media). Had our governing bodies such as the World Health Organization created a broad “behavioral overuse disorder” category that could have been applied to any behavior, this could have been avoided, but alas. Surely, we worry about the cat addicts as much as we do the video game addicts?
Therapy is becoming increasingly female with over 70% of therapists being women. As with primary education, this may lead to some feminization of the entire process (and my impression of male therapists is that overall they aren’t exactly the manliest types either, self included). By contrast, although there are many women D&D players, it tends to remain male dominated. Sure, stereotypically speaking, these aren’t necessarily the jocks, but still. Finding ways to meet men and boys (as well as women and girls disinterested in traditional therapy) where they are is a good thing.