You may be asking – what makes Dungeons & Dragons therapy groups different from other mental health or therapeutic social skills groups?
Remember as kids when we walked without supervision to playgrounds and parks, played and made friends there, engaged in fantasy games by ourselves or with our friends, or just stayed home and played board games and card games? And do you remember all the movies in the 90’s that seem to have a common theme: exploration and adventure? What happened to these innocent games and films that taught us so many small lessons about life and social interaction? It doesn’t take a lot of thought to discover the answer - with the introduction of smart phones and highly addictive video games, the gap between ourselves and our children and the world of imagination is rapidly growing wider, to the extent that it feels like many of us don’t know how to play without a screen in our face anymore.
As a therapist, I am always seeking tools to help my clients re-engage their brain in real life situations and exploration so that they can more frequently disengage from the ubiquitous and carefully designed electronic media we are all being flooded with. While I pride myself in my ability to connect with children and adolescents with ease I learned that, for children, coming to therapy can be an aversive experience, especially when the child believes that they do not need therapy but their parents believe they do. Think about it – the goal of coming to therapy is to open up and be vulnerable with a stranger. Now add the possibility that the child is depressed or highly anxious and you start to understand why this experience can be so intimidating.
In my day to day interactions with children I quickly realized - all my efforts are competing against something really powerful: the electronic gaming world and the feeling of being understood by and deeply connected to strangers on the internet who share their interests. I decided to search for something that might be able to captivate my clients to a greater degree than just coming to therapy and talking out the things that have been hiding deep within. In this search, I came across Dungeons & Dragons. I was intrigued by how a narrative guided by a Dungeon Master (DM) or Storyteller supports players in collaborative story telling in which each player brings to life their own unique and fully customized fantasy avatar.
About two years ago, my colleague Anne Szostek and I embarked on a journey bring this game to a small group of neurodivergent boys to whom we’d been providing behavioral therapy. We wanted to use the game to support these boys gaining new skills to navigate their worlds in school and at home. Through the game, we helped them build a supportive community and taught them skills to manage their anxiety, depression, self regulation challenges, and electronics addiction. What we noticed was truly amazing - not only did these boys had the opportunity to create very special social bonds but they rapidly learned to self-regulate, self-advocate, set boundaries, practice social scripts in real time, make choices as a team, and seek advice from team members and adults. The game created a separation between their true selves and their characters that allowed them to freely explore real world feelings and scenarios without the anxiety associated with facing real world consequences. And most importantly, all of the kids had a great time and looked forward to their therapeutic sessions, even spending significant time outside of the game preparing for the next meeting.
The game has rules (honestly, a lot of rules) for players to follow, but it doesn’t take a whole lot of fancy equipment, and no screens are necessary. Each player has a character sheet that explains everything about who their character is, their unique strengths, and what they are capable of. At the beginning of the game, our characters form a team and the storyteller reveals their goals to them, but it is up to the players themselves to decide how they will achieve them. When it comes time to face a challenge, we decided what actions our characters will take and roll dice and the Storyteller tells us whether we were successful or not. That's all you need to play the game - dice, paper, and writing implements - although we also incorporate maps and print images into our games to support focus and spatial awareness.
What is really interesting from a therapeutic perspective is that players re-enact real or imaginary situations from their past, present, or future with ease because they are in a safe environment amongst peers. Anything players say is taken seriously, which means that they can try out a wide range of behaviors in the game that would not be feasible in real life and see for themselves the natural consequences of their actions, whether good or bad. The game can be fully customized based on the needs of each individual player – there is no such thing as a set story line, the story is something that is created by all of the players working together.
Is roleplaying therapy evidence based?
Exploring hypothetical scenarios through roleplaying therapy, such as we offer through our therapeutic D&D groups, has a strong evidence base. Role play itself has been found to facilitate changes in how people approach things more than psychoeducation does (Elms, 1967). It also increases self-esteem and relational attitudes (Gorman et al, 1990), self-awareness and empathy (Minds on fire, 2014), critical and ethical reasoning (Simskins, 2010), helps establish friendships, and creates an opportunity to practice social skills (Billieux et al, 2007, Depuis & Ramsey 2011). All these benefits are evident regardless of what type of therapeutic approach and theoretical background the clinician works from (Matthews, 2014). I found research that suggests that roleplaying therapy can teach children and adolescents about self-concepts, social skills, anxiety management, and lead to effective behavior changes (Kipper & Ritchie, 2003). The reenactment of imaginary or real situations support clients in understanding emotions, identifying triggers, modeling ideal behaviors, and practicing skills in a safe environment (Matthews et al, 2014). Players can explore hypothetical scenarios safely, since the therapists and the group accepts everyone’s choices without judgement
What about Dungeons & Dragons therapy groups?
Are those evidence based too? I have learnt that in the past 10 years, D&D has emerged as a new way of conducting therapy (White, 2017). Researchers point towards its effectiveness in the ways it supports children and adolescents in their development (Zayas & Lewis, 1986), and scholars are now also offering insight into how this platform can support individuals with depression (J. Hughes, 1988). And in April 2024, a study from James Cook University found that it "demonstrated significant decreases in depression, stress and anxiety and significant increases in self-esteem and self-efficacy over the study period" (Merrick, 2024).
In addition, evidence suggests that Dungeons & Dragons facilitates higher levels of creativity (Chung, 2013), empathy (Rivers al, 2016), success in maintaining friendships, feelings of connectedness (Wilson, 2007), increased ability to consider group needs, and greater moral reasoning (Wright et al, 2020). Researchers at University College Cork found that Dungeons & Dragons supports individuals with mental health issues as it provides a form of positive escape, self-exploration, and social support (Storey, 2024). Since the game is collaborative as well as creative in nature, it allows for a sense of control and emotional connection through which it is easier to deal with feelings of powerlessness. Players collaboratively build a world of their own creation where each participant can express themselves freely. Since you are creating your story collaboratively, this creates this amazing shared experience amongst players. During the game players can externalize their feelings and struggles onto the characters they design, which in turn helps them process their emotions freely. And since the players are part of a team, the game encourages teamwork and critical thinking. What an amazing way to gain confidence and find your voice!
The way Dungeons and Dragons is structured makes it easier for therapist to challenge and support the players because the storyline is built around the participants’ individual needs. We meet with our participants and their families (for younger clients) beforehand, learn about their symptoms and goals and get the parents on board with the goals the client chooses. Once we know our client’s goals, we support them in creating a character with a backstory which is personal to them. Once the characters are ready and the participants learn the rules of the game, the Storyteller (my colleague Anne) comes to life, laying out the story and creating prearranged opportunities where participants will be challenged in an environment that is safer and much less intimidating than a typical group therapy session. This safe game environment essentially becomes the place where an array of feelings are processed and new skills and behaviors are practiced without real world consequences. Taking on a different character makes it possible to remove yourself from your problems and look at them almost like an outside observer. If things are not going well in the game or between the players, the two clinicians in the room are able to adjust the story to make sure clients feel supported in advocating for themselves and having opportunities to grow.
We noticed that D&D often provide opportunities to learn about speaking up and learning to have difficult conversations and this can be very helpful for someone who is living a life where anxiety or depression is a permanent fixture. Players learn to set boundaries and express important needs, and practicing these skills in the game translates to more confidence in real life. Clients with depressive or anxious symptoms are challenged to address negative thinking patterns by reframing them, and have team members who will be by their side supporting them to do this. The practice of supporting one another perpetuates the development of more positive self-talk and the feeling of acceptance from others. These group dynamics naturally improve social skills and support players to think through how to navigate a variety of social situations. Since they are part of the team, players learn what it means to consider others in their actions, and immediately see the benefits of doing so.
At the end of each session, the two clinicians and the players process the events and identify insights about themselves that they gained during the session. This process supports participants communication and cooperation with each other, and allows them to integrate their in game experience into their everyday life.. If the group is facing a conflict, we use this time to support players to manage it in a way that respects each individual's autonomy while also maintaining the cohesiveness of the group.
We are excited to see that institutions such as John Hopkins have started Dungeons & Dragons therapy groups, and hope that we see a wealth of new research on this therapeutic modality soon. With coverage from authoritative publications such as the The Guardian, Wired Magazine, and Time Magazine, we believe that we are at the forefront of a new way of providing group therapy that will revolutionize mental health care.
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References
Billieux, J., Chanal, J., Khazaal, Y., Rochat, L., Gay, P., Zullino, D., & Van Der Linden, M. (2011). Psychological predictors of problematic involvement in massively multiplayer online roleplaying games: Illustration in a sample of male cybercafé players. Psychopathology, 44(3), 165–171. https://doi.org/10.1159/000322525
Chung, T. S. (2013). Table-top role playing game and creativity. Thinking Skills and Creativity, 8, 56–71. https://doi.org/10.1016/j.tsc.2012.06.002
Elms, A. C. (1967). Role playing, incentive, and dissonance. Psychological Bulletin, 68(2), 132. https://psycnet.apa.org/doi/10.1037/h0020186
Gorman, D. M., Werner, J. M., Jacobs, L. M., & Duffy, S. W. (1990). Evaluation of an alcohol education package for non‐specialist health care and social workers. British Journal of Addiction, 85(2), 223–233. https://doi.org/10.1111/j.1360-0443.1990.tb03075.x
Hughes, J. (1988). Therapy is fantasy: Roleplaying, healing, and the construction of symbolic order. In Anthropology IV Honours, Medical Anthropology Seminar, Dept. of Prehistory & Anthropology, Australian National University, Canberra, Australia
Kipper, D. A., & Ritchie, T. D. (2003). The effectiveness of psychodramatic techniques: A meta-analysis. Group Dynamics: Theory, Research, and Practice, 7(1), 13. https://psycnet.apa.org/doi/10.1037/1089-2699.7.1.13
Matthews, M., Gay, G., & Doherty, G. (2014, April). Taking part: Roleplay in the design of therapeutic systems. In Proceedings of the SIGCHI conference on human factors in computing systems (pp. 643–652), Toronto, Ontario, Canada. https://doi.org/10.1145/2556288.2557103.
Merrick, A., Li, W.W., Miller, D.J. (2023). A study on the efficacy of the tabletop roleplaying game Dungeons & Dragons for improving mental health and self-concepts in a community sample. Games for Health Journal, 13(2) pp. 128-133
Rivers, A., Wickramasekera, I. E., Pekala, R. J., & Rivers, J. A. (2016). Empathic features and absorption in fantasy role-playing. American Journal of Clinical Hypnosis, 58(3), 286–294. https://doi.org/10.1080/00029157.2015.1103696
Simkins, D. (2010). Playing with ethics: Experiencing new ways of being in RPGs. In Karen Schrier & David Gibson (Eds.), Ethics and Game Design: Teaching Values Through Play (pp. 69–84). IGI Global.https://doi.org/10.4018/978-1-61520-845-6.ch005S
Wright, J. C., Weissglass, D. E., & Casey, V. Imaginative role-playing as a medium for moral development: Dungeons & Dragons provides moral training. (2020). Journal of Humanistic Psychology, 60(1), 99–129. 10.1177%2F0022167816686263. https://doi.org/10.1177/0022167816686263
White, C. (2017). Dungeons & dragons is now being used as therapy. BBC. https://www.bbc.co.uk/bbcthree/article/ab3db202-341f-4dd4-a5e7-f455d924ce22
Zayas, L. H., & Lewis, B. H. (1986). Fantasy roleplaying for mutual aid in children’s groups: A case illustration. Social Work with Groups, 9(1), 53–66. https://doi.org/10.1300/J009v09n01_05
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