How to make a Therapeutic Game
Therapeutic By Design
By Dr. Brian Quinones, Ed.D, LPC, ACS, Autplay Certified
Full disclaimer – I do own copies of many of the games that I will be talking about, but I do not own any stock in their companies, did not create, or help create any of these games for profit. I will mention whenever I mod a game or change it from its original intent to fit my clients needs. It is important to note that yes I am a therapist, but this blog is not intended to be therapy. I will offer advice, tips, and other guidance on my blog with the intent to illustrate important life skills, provide entertainment, inform, and at times empower the reader.
If you or a loved one is struggling with mental illness or are facing any kind of crisis seek local professional help, and/or contact authorities or emergency professionals for assistance.
How to make a Therapeutic Game
Today’s topic that we are going to discuss is the notion of designing a therapeutic board game or roleplaying game. I want to address some of my thoughts on the topic and then discuss what kind of impact it could have towards use in session, associated treatment goals, interventions, activities and skills and benefits. Additionally, I will mention where I feel the competency of the clinician will fit into game design, and the limitations of that places on the designer. Lastly, I will talk about accessibility, what games are currently being made, what I think that means for my part of the field going forward, and provide a summary at the end.
My Thoughts on The Therapeutic Game
Please Don’t Bore Us
As some of you may know I have spent the last couple of months knee deep in play therapy theories, and the last year pushing for group therapy for Intensive In-Community group therapy with the Autism population, with an emphasis on the use of tabletop games in session to build up social skills. Between that, the last twelve months of trainings and convention hopping, the idea of designing a therapeutic game continues to be a theme. On more than one occasion people ask me how would I create a therapeutic game, and for more than five years I have talked to Timothy Grant about doing it ourselves. Over the years, I have leaned on the side of, leave the game designing to game designers.
That is not to say I believe therapists should not be game designers. There is obviously room for overlap between the two fields. I am constantly hacking and modifying games in the office to suite my clients’ needs. The problem, at least in my part of the field, is the connotation that the phrase “therapeutic game” has to me. Often the players receive prompts to answer therapeutic questions. At their best, they are a decent social ice breaker game. At their worst my clients see that coming a mile away, and it turns them off to talking to me. If you’re not into a game that is secretly a list of prompts for your journal, your going to get really bored, really quickly. Boredom breaks one of my only rules for session. Day one I tell my clients, “If you’re bored chances are, I’m bored too. Let’s not be bored.”
About 8 years ago, I was working in the home with this one family, tried a therapy game and immediately decided to never use one of them again. Their good training tools for therapists, but often feel unnatural and forced for kids or teens. The next session I went back to playing chess with the client, and with the family we played a social deduction game like Werewolf, called Traitor. Why do therapy games fail in session? I believe it is because they are therapy wrapped in the illusion of a game. Any type of gamer, video, or board gamer knows what a game should feel like, what playing feels like, something that was designed to be fun first.
The Rules of What I Do
So, let us say as a game designer you manage to get through the fun barrier, you now have to deal with the real issue at hand, the therapist or professional support. As a frame of reference, from a New Jersey Intensive In-Community therapeutic perspective let us say there are four ways to go about this.
1. The Self Help or Mentoring perspective (High School or Certification)
2. The Behavioral Assistant or Support Services (Bachelors or Certification)
3. The Professional level (Masters)
4. The Licensed Level Clinician (License in Counseling, Social Work, Psychology, etc)
Each of the four have different areas of competency necessary to perform their job. When looking at the self help or mentoring level, think of it more like tutoring, social skill building, emotional support, or role modeling like a Big Brothers, Big Sisters program would fit, and that could be for all ages. I believe that this level may prove to be the most important for game design, it is the most flexible and can make a firm building block for a more detailed therapeutic design. The other three levels I talked about at length during my last post but it is important to make the connection to game design itself. The Behavioral Assistant can focus on anger management, parenting skills, stress reduction, problem solving, decision-making, risk reduction and mental health education. From the professional level you start to see the use of therapeutic modalities such as play therapy, drama therapy, art therapy and/or music therapy. At this level you can also provide clinical consultation/evaluation under the direct supervision of a clinical professional. Lastly the clinician level is fully licensed and provides counseling services, symptom reduction, and can perform licensed level assessments.
“If you’re bored chances are, I’m bored too. Let’s not be bored.”
When you look at the professional level and licensed level, the modality used by the therapist starts to become a main influencer and/or deterrent towards the use of gaming in session. While it is true that the client may dictate the direction of the session, the modality determines the tools available for the therapist to draw from. So, for example, a pure behavioralist may only focus on changing the behaviors of a client, while a cognitive behavioral therapist would look at the thoughts, and feelings of the client as well, or a narrative therapist may ask questions in order to generate opportunities for the client to describe their life in vivid detail. One last caveat before going further into game design. There are two schools of thought that can influence the way a therapist interacts with her client. Direct verses Indirect teaching. The more indirect a clinician the less likely they are to use any kind of game or form of play that the client themselves did not introduce, select, or come up with. From what I have seen, certain forms of play therapy will not use games or board gaming at all. It goes against some of the more child centered models. But there is a catch to this that I noticed within the indirect play therapy community.
What does this mean for game design?
I believe the biggest question to answer is, can you create a game that fosters therapeutic growth without calling it therapy. Essentially, if the game functions on the professional level or higher, then does that mean you need a therapist to run it? As I mentioned in the panel we had at Metatopia, I believe that this hurdle becomes potentially dangerous, if the game elicits an abreaction response without someone with the clinical expertise to help triage the situation you can reintroduce traumas that the player is not ready for. In roleplaying games or live action roleplaying games the player may often have a cathartic reaction. This means the player may have the opportunity to release a strong repressed emotion. An abreaction on the other hand is the release of a repressed emotion which happens by reliving the experience. A person could safely explore their abreactions through hypnosis, EMDR or other forms of suggestion, memory exploration, and mind body awareness, with the aid of a clinician. The problem with abreactions in play is there is a chance for traumatic memories to resurface without the player even knowing they existed. And without the aid of a trained therapist the player can go through this experience without ever being able to reprocess those traumatic memories. In short, the closer your game gets to therapy, the more only a therapist can facilitate it.
That being the case, let us double back a bit. In general, your game for the client should be fun, but for the therapist it should have the flexibility to step beyond the mentoring piece. Providing psychoeducation could be something as simple as frustration tolerance, which most games that provide a challenge will do. I believe that if we target specific skills and/or the positive aspects of play, based on what the game or activity is being performed, then we can create opportunities to encourage growth for the players while giving therapists the tools they need to go deeper than mentoring or support in session. Over the years I have become more directive and goal orientated with my therapeutic sessions.
And since our state contracts are so demanding I have been forced to be more detailed about how I integrate Cognitive Behavioral Therapy, Play Therapy, and tabletop gaming. I am currently looking for games that help address one of six target goals. Those goals are emotional regulation, social functioning, relationship connections, anxiety reduction, sensory processing improvement, and behavioral change. I look to see what type of intervention, strategy, or modality a specific game could line up with and from there I pick what type of activity or technique the game best represents. Sometimes activities could just be the level of play the person is capable of performing at that time. Lastly and perhaps most important for game design purposes, what type of play skills and benefits are being introduced by this game. The general areas that I draw skills and benefits from are mostly associated with the powers of play that the Association of Play Therapists provide on their website. The general categories describe play as benefiting the facilitation of communication, fosters emotional wellness, enhances social relationships, increases personal strengths, and I include a separate category for improves behavioral change. There are over twenty subcategories but as a therapist, if your game can target anyone of the main powers of play and provide an opportunity for major practice and improvement I am sold.
The Direct Approach
Now back to that catch we were talking about with indirective forms of therapy. Those types of therapy have a knack for accessing the unconscious mind. The client brings everything they need to work on with them, all the therapist has to do is provide the right tools and environment to allow them to do it themselves. For example, the use of a sand tray and mini figs during therapy could help let the client explore what is going on under the surface in a safe manner. What I noticed is, that even amongst the therapists who feel that gaming should not be part of session they do allow writing prompts or other images that get at the unconscious mind. I personally feel that this leaves a lot of running room for games like Dixit, and Mysterium, something with beautiful art that is thought provoking and can lead to that unconscious self-expression. I did see pictures from the 36th Annual Association of Play Therapist Conference where people were laying out Dixit cards on a table. So, there is room for games like that, you just need the right approach to make that connection.
Over the years at Metatopia I have often asked, is the game fun because of its design, or because of the person demonstrating it. When someone is good at their craft, and excited to share what they have done that can spread through the table and influence how the player feels about the game. Your joy is infectious, and this can happen in session too. If I am introducing a game, I am excited about to a client that can change their interest level. But in session you need to know the game your playing with your client, you cannot spend the whole time reading the rules, and it must be simple enough to explain in a timely fashion. Recently I had the privilege to playtest a roleplaying game a peer in the field is creating. I told the designers that ultimately, for your roleplaying game to be therapeutic in session, it will rise or fall on the strength of the game master and the people playing it. The strength of the player, the strength of the game master, will also be reliant on the strength of the therapist. The more complicated your game the higher skill level the therapist needs to have going into it. Not just as a clinician but as a gamer. And if a therapist cannot relate to the role of the GM in your game design, they are not going to use it, and probably should not. So as always think of your target audience, not just the kids you want playing it, but the people you expect to run it. It is much easier for me to convince my therapists who are not gamers to play Blokus than it is to play Scythe.
Therapy can be fun, that is the whole point of my company and what I do as a licensed counselor. Play itself can be therapeutic, but if you are looking to make a game into therapy, it might be best to change your point of view. I think there is a serious safety concern when you design a game to be therapy, is it a game, or is it therapy, should it be both? I think they can be both, but on a pure ethical standpoint, you cannot advertise your game as being a therapeutic process if you cannot guarantee a licensed and/or trained professional is the one using it. Or at very least has consulted for safety issues. It is better to have a system that has the potential of being a therapeutic tool in the right hands, but its main goal is to provide opportunities to play in a healthy way. One can provide psychoeducation through a game that facilitates growth in communication, emotional wellness, social relationships, personal strengths, and positive behavioral change. The paradox is, you need a game that a therapist can see the value in, be able to easily pick up and play, but does not call itself therapy so others will want to play it. In future blog posts I will explain what my database will aim to do, and I will be giving examples in coming weeks for implementation with specific types of games and clients.