D&D usage in therapy—more research is needed

For therapists like Colman, D&D’s rising popularity seems to help persuade patients that it’s a possible therapeutic tool.

“I think that the popularity of TTRPGs as ‘niche’ games and as an increasingly mainstream ‘brand’ (featured in popular movies, cartoons, and TV shows) has helped us reach wider groups,” Colman said. “Whether it’s potential clients or funders, when we ask, ‘Have you heard of games such as Dungeons & Dragons?’ The answer is increasingly ‘yes,’ even if they haven’t actually played them.”

D&D became the focus of therapeutic research in the mid-1990s, but only a handful of papers have shown its possible effectiveness. “There is currently very little good-quality, peer-reviewed evidence published in scientific journals on the benefits of TTRPGs,” said Colman. “The challenge has been the very small sample size of the research projects and the challenge to find funding.”

Colman and his collaborators at Game Therapy UK are working with several UK universities to create objective benchmarks to test the effectiveness of D&D as a therapeutic tool. Colman said his team has “several very interesting projects that [they] are currently exploring, including the effects of using TTRPGs with military veterans with mental health conditions caused by their military service, the experience of autistic adults and young people playing TTRPGs, and the impact of lunchtime TTRPG clubs on school attendance of children with special educational needs.”

Some results are in

While the research is ongoing, many academics and therapists say they have already seen positive results implementing D&D as a therapeutic tool. Most recently, a group of researchers at the University College Cork published findings in the International Journal of Role-Playing showing that D&D can positively support a player’s mental health state.

How does this work? In a standard D&D group therapy session, gameplay begins with an introduction to allow the patient/player to get into their character’s mindset; the game then runs for 70 to 90 minutes, followed by a 15- to 20-minute debriefing session to allow for discussion. The session is intended to provide a safe space for people to explore past trauma and work on social anxiety, depression, or other issues in a productive way.

Through the session, the therapist creates specific scenarios for individual players and the group to interact with. These scenarios may be a partial re-enactment of an issue or memory an individual has faced (such as dealing with a difficult person like a bully or abusive family member) or a unique situation that challenges an individual with a tough decision or invokes an emotional response. The player-driven narrative of D&D enables players to respond to these scenarios however they choose, allowing them to react candidly. The therapist may then allow the individual to sit with their scenario while giving the other players a separate situation or bringing the individual back into the larger narrative after completing the scenario.

By interacting with situations as a character, players can potentially enjoy some emotional separation from their personal responses. “A lot of what I end up doing implicitly with D&D is helping people shift from a self-focused view of their emotions as a problem to a systems lens understanding... recognizing our emotions are adaptive and an outside-in phenomenon instead of an inside-out judgment of our worth,” explained Vinny Malik Dehili, a staff therapist at Vassar College.

“So D&D helps people mentalize and think in terms of ‘why does this person feel this way or act this way?’ If I have a character that’s the opposite of me—like I’m more accommodating by nature and I want to be more assertive—I can think about their backstory and say, ‘Well, what would have happened to them in their life to make them have to be this way?’” he said.

During these sessions, the therapist may temporarily pause the game to briefly address the therapeutic processes the player is experiencing outside of the game, depending on the player’s emotional state. However, after the session, the therapist will typically dive much deeper into the players' responses and reactions to the day’s scenarios. Addressing the therapeutic processes post-game gives the session stricter boundaries, containing therapeutic experiences and breakthroughs to a specific space and time. These guidelines are similar to role-playing techniques for other therapeutic processes, such as cognitive behavior therapy (CBT). In all cases, these strict boundaries allow the character and player to separate their identities and struggles more easily.

The cross-over effects between character and player are called “bleed,” where “bleeding in” happens when part of the player’s personality and backstory affects the character, while “bleeding out” occurs when the character’s personality or backstory affects the player. According to experts, this phenomenon helps when measuring the effectiveness of D&D in group therapy settings.

“The main priority in using D&D as a therapeutic tool is the safety and wellbeing of the participants, as ‘bleed’ can occur where something within the game session can impact an individual while they are out of that space,” said Dr. Jeremy Jones, a licensed professional counselor and CEO of Thinking about Thoughts Counseling Services, which offers D&D group therapy. “A trained facilitator can set up the environment, incorporate safety tools, and have a skill set in working with a group setting.”

The “group” in D&D group therapy

While D&D group therapy can help individuals, it has also been shown to strengthen group dynamics, as it can encourage individuals to become more sociable and assertive as ways to solve problems and further the story. Experts found that these benefits seemed to be especially helpful during the forced isolation caused by the COVID-19 pandemic. However, this seems only to work when the group has a collaborative instead of a competitive mindset.

“The more you can follow the group’s needs or energy rather than feeling like I have to make this story or make this intervention happen right now, that usually ends up being a better experience,” Dehili added.

To get the most productive and positive group experiences, therapists using D&D as a therapeutic tool may need to create additional boundaries and rules to ensure the session benefits everyone, not just one individual.

“It’s important to have safety tools within the game, talking about what content is acceptable and what’s not acceptable based on the [players’] traumas or histories,” Dehili said. “D&D, like most things within our society, has a history of white supremacy and other kinds of racism, as well as misogynistic tropes. So it’s really important to be intentional with how you set up the frame of the group in terms of what’s going to be leaned into and what’s not. We can use humor, slapstick, and other modalities, but we’re trying not to make parallel political and social references. We’re trying to avoid the stereotypes—for example, the name ‘hag,’ which is this monster, and it’s also usually in a feminine figure, or orcs being darkly skinned and brutish. So we want to invite people to notice what activates them and be able to shift within the space.”

The range of game settings, plotlines, and characters allows therapists to create a huge variety of therapeutic scenarios for patients. “There is no ‘standard’ way of playing D&D, and it can very much depend upon the group that someone is in,” said Ian Baker, a professor of psychology at the University of Derby.

Experts recommend combining D&D with other therapeutic sessions and methods instead of using it as the only source of therapy. “D&D can be complicated and very rules heavy, which can be a barrier to entry in itself and should be a consideration,” said Jones. The game’s complexities can dilute its impact on a patient compared to other therapy techniques.

However, if the therapist/DM can navigate the rules-heavy format while encouraging positive group dynamics, the results can be significant.

“Generally, if the group is thoughtful and considerate—and, most importantly, keep the game fun for all involved—it’s highly likely to be a positive gaming experience,” said Colman.

Kenna Hughes-Castleberry is the science communicator at JILA (a joint physics research institute between the National Institute of Standards and Technology and the University of Colorado Boulder) and a freelance science journalist. Her writing focuses on quantum physics, quantum technology, deep technology, social media, and the diversity of people in these fields, particularly women and people from minority ethnic and racial groups. Follow her on LinkedIn or visit her website.