Dungeons and Dragons has enjoyed a significant revival in recent years, due in part to popular streaming shows like Stranger Things and Critical Role. Once seen as the pinnacle of geek culture, the role-playing game (RPG) is now a hit with a new generation of players. But while many people may view it as just a form of escapism, the game has also tapped into the imaginations of therapists and psychologists who see it as a potential tool to improve emotional and social wellbeing.
A brief history of a fantasy
Dungeons and Dragons, or D&D, was first invented in 1974 by Gary Gygax and Dave Arneson who took inspiration from other miniature wargames. The game quickly grew in popularity to become the genesis of modern RPGs, inspiring a vast proliferation of similar game systems. Since the 1970s, D&D has been enjoyed by millions of people across the world, who have used it to create and play a multitude of races with different occupations and in various fantastical scenarios.
Veterans of the game will often laud it for its social dimensions, its creativity, personal empowerment, and the fact that it is almost completely based in the imagination. At the time, there was even interest from researchers who saw the game’s potential in therapy. However, research into the game’s use in treatment quickly evaporated when D&D became associated with the Satanic Panic that swept across America in the 1980s.
The Satanic Panic was a hysterical movement inspired and sustained by TV pundits, politicians, and religious leaders who believed that a network of shadowy cultists in influential positions were conducting occult rituals, holding orgies, and sacrificing or abusing children. Much like QAnon these days, supporters of the movement were convinced that dark forces were working to destroy American culture, undermine the political system, and destroy traditional Christian values. Unfortunately, D&D became a focus of this hysterical movement after it was incorrectly linked to a series of murder-suicides in the US.
We may trivialize the idea today, but the conspiracy ruined many lives in North America, with a veritable witch hunt leading to hundreds of accusations and court trials across the country. D&D and its supporters were a key target of evangelists who carried out a high-profile media assault and decried it as an occult tool designed to lead children towards demonic possession. Of course, all these accusations and spurious connections were ultimately unfounded and no causal links between the game and suicides or violence were ever established. Nevertheless, the influence was so strong that it even crossed the Atlantic and impacted the perception of the game in the UK.
This negative association had a lingering effect on D&D, but as time went on, and the horrors concerning demonically possessed geeks murdering and rampaging failed to manifest, the game simply became uncool and the stuff of fringe culture. But over the last decade, many things that were once deemed geeky have enjoyed a popular resurgence, and D&D is very much among them. This is mostly due to celebrity endorsement, frequent pop culture references, cultural nostalgia and pseudo-nostalgia for all things 1980s, and above all, its support from its massive community of players. The game has even been turned into a successful Hollywood movie in recent months.
Now a new generation of psychologists and therapists are joining this growing enthusiasm for the game by using D&D in their clinical work.
Dungeons and Dragons in therapy - does this count as a medicine check?
“When treating a client that plays D&D in their spare time, I ask them what they’ve learnt from their characters, and how they engage with other players at the table,” Francesco Causo, a clinical psychologist in Australia, told IFLScience.
“I find it is a great gateway for rapport building, but primarily to gauge a clients’ emotional awareness and ability to take on different perspectives.”
For Causo, who has been playing the RPG since he was a teenager, a player’s character choice is a wellspring of information that is useful for treatment.
“I often find that players choose their characters with an intention behind it, and as a therapist I am curious of what that intention is. Sometimes, our characters address needs and experiences that we crave and lack in our life, and it is a great starting point to address these in therapy.”
For psychologists like Causo, RPGs like D&D offer a range of positive benefits. For one thing, players have the chance to create characters that reflect aspects of themselves, such as behaviors, interests, and identities, that they may want to explore in a safe environment. Moreover, it is collaborative in nature, so rather than relying on competition or antagonism, players are encouraged to work together to problem solve and find solutions that benefit the party. This can serve as excellent practice for setting boundaries or having difficult conversations.
Also, being able to play a character with drastically different ideas, interests, motivations, likes and dislikes, is valuable for not only testing alternative approaches to your own thinking, but to gain perspective on other ways of being – seeing the world through another’s eyes – which can foster greater empathy.
In many ways, the game as a tool in the therapeutic encounter is not necessarily new. Play as an activity in itself has various mental health benefits, and has been used to help children in therapy ever since psychology emerged as a field. But while we might think that playing is only suitable for kids, it has proven benefits for adults too, such as fostering adaptive behavior, creativity, role rehearsal, mind/body integration, increasing self-esteem, and decreasing stress. Play also helps us process new information and to test behaviors in a safe environment.
The largest restriction here is less about the activity itself but rather the social perceptions of play for adults who think they should just "act their age".
D&D is such a powerful tool for therapy because it offers a subtle way to bypass this “awkwardness”. It’s fun and engaging above all. This “is a crucial component of what makes these environments therapeutic”, Causo added, “because they reduce the clinical judgment and consistent mindful observation from a therapist, which allows players to let their guards down and choose when to engage with introspection, or just act as their characters.”
It would be a mistake to suggest that such roleplay activities are unique to the use of D&D in therapy. In fact, so many therapeutic approaches rely on roleplay that it would be impractical to list them all here, but two good examples include psychodrama and Schema therapy.
So the use of D&D’s roleplay mechanics fits well in this therapeutic landscape, but psychologists are interested in more than just what our characters say about us. The decisions we make in-game are just as significant.
“If you're working with somebody, and you say, ‘you seem to have a hard time with eye contact’, they might immediately be like, ‘No, I don't like what you're talking about’”, Dr Megan A Connell, a licensed psychologist and Therapeutic Dungeon Master (DM) explained in an interview with IFLScience.
“But if we're role-playing, it's more like I’ve noticed it socially, and I can ask ‘your character doesn't want to make eye contact with the NPCs [non-player characters], why’s that?’ They can then be like ‘oh, well it’s because of this’, and then they can feel much more able to express what's going on than if you're talking about them as a person.”
By addressing the actions and decisions made by a character, rather than the patient themselves, there is a distance between them and the content being discussed. “We have that separation, when it's a character, which seems to make it much more approachable for us to deal with, because we can say ‘well, it's not really me. It's my character struggling with this, and this might be why they're struggling with this thing.’”
Connell first encountered the game as a child but reconnected with it years later after following other pursuits. Now she has incorporated D&D as a formal aspect of her treatment. “I started with some pilot groups where I would just run a one-off session and see if there was any interest,” she explained. “And then I started a couple of groups, which went really well.”
Soon, after figuring out the population she wanted to work with, she ended up with three therapeutic D&D groups running each week. The idea was extremely successful, but then the pandemic hit and things slowed down.
It was at this point, in the downtime imposed by the global crisis, that Connell started working on a book, Tabletop Role-Playing Therapy: A Guide for the Clinician Game Master, which recently came out. Now Connell is looking to return to DMing for new groups of players, and with the growing enthusiasm for D&D, it is likely she will get plenty of interest.
What's next for the adventure?
D&D, and other RPGs, could well offer a range of treatment options for therapists, but as with all burgeoning methods in clinical settings, there are dangers. Any new therapeutic intervention that is in its infancy is at risk of someone doing something that gives it a bad name. Connell stressed, “If we get even one big profile case of, you know, somebody inappropriately running a therapeutic game, mistreating people, doing appropriate things in games, and it gets a big amount of attention, it could kill the whole profession.”
That’s why we need more research on the benefits of D&D in practice in this context. Although more researchers are starting to take notice of the game, alongside other RPGs and tabletop games, there simply is not enough data to know what the valuable areas for therapy are and how to apply them for different needs.
But above all, as Causo stressed, the main thing to remember is that D&D is an RPG and not therapy on its own, “but like many adaptive activities (sport, theatre, music), they can enrich one’s life and provide opportunities for reflection, and can foster mental health wellbeing. Differently from other activities, I believe that RPGs provide a unique opportunity to work on oneself at a pace that is comfortable.”