Improving treatment with role-playing games

Psychologists frequently use games to connect with, diagnose, and treat children, but some types of gameplay are also proving effective as a therapeutic intervention for teens and adults. Combining aspects of evidence-based interventions such as role-playing, psychodrama, and group psychotherapy, more and more psychologists are using tabletop role-playing games as a treatment modality for all ages. So far, research in the area is limited, but psychologists using the intervention believe it shows promise for improving symptoms of many clinical disorders.

Tabletop role-playing games, or TTRPGs, involve role-playing in an open-ended, story-based game—most notably, Dungeons & Dragons, which celebrated its 50th anniversary in 2024—led by a therapist “dungeon master,” or more generally “game master” (GM), who narrates the game and allows players to make decisions that determine outcomes. Therapeutic game groups typically include four to six patients who continue in a series of games for several weeks or months. Many therapists use TTRPGs as a form of group therapy, debriefing with patients at the end of each session. Some clinicians also see their group members individually outside the group. In either case, the goal is to equip participants with therapeutic tools they can apply in real life, from basic social skills to coping mechanisms for anxiety, depression, trauma, and attention-deficit/hyperactivity disorder (ADHD).

The intervention builds on existing psychological research about role-playing, which studies have shown can support mindset change, build self-esteem, and improve interpersonal relationships (Henrich, S., & Worthington, R., Journal of Creativity in Mental Health, Vol. 18, No. 3, 2023opens in new window). Participants play as characters, often co-created with the therapist as a vehicle for addressing therapeutic goals. For example, someone with anxiety may play a courageous character, while another player might create a character that gives them a new perspective, such as one with a different gender or race. Players might also create characters that represent their younger selves as a way to address adverse childhood experiences.

The game master creates scenes in which players embark on a mutual adventure. In therapy, the GM can tweak the game to better support patients’ struggles—for example, encouraging an anxious player to take a risk. While this world is imaginary, proponents say it can be a powerful conduit for self-knowledge that enables participants to make lasting changes in their everyday lives. “TTRPGs are essentially a simulation machine,” said Jared N. Kilmer, PhD, a clinical psychologist and applied games researcher. “You observe other people, respond to stimuli, and take actions at a much faster pace than in real life.” That said, players can also slow down or pause the game to process events with other players or the therapist.

“Trying on” new life skills as a character in one of these simulations is lower stakes than trying something new at work or in school, where results carry the weight of real-world consequences, added Heather Whittall, PsyD, a Colorado-based clinical psychologist who uses TTRPGs with patients. “When someone messes up, they don’t feel as bad because it was their character,” she said. “The consequences become the character’s problem.”

In the structured environment of gameplay, therapists can ensure players feel emotionally safe to take risks in the game. Megan Connell, PsyD, ABPP, a clinical psychologist and author of Tabletop Role-Playing Therapy, leads TTRPG therapy groups for adolescent girls. At the start of new groups, Connell helps players establish topics they don’t want to include in the game, such as spiders, drug use, or sexual innuendos (boundary setting is handled differently when therapeutic exposure is necessary, such as in treating phobias). During gameplay, participants use poker chips to communicate that they’re uncomfortable with something in the game. Along with creating an environment that feels safer for players, this communication often translates to the ability to set boundaries outside of therapy. “A lot of people I work with aren’t used to people respecting their boundaries, so this can be a corrective experience,” said Connell.

Joining a game group can make pursuing mental health support feel less intimidating—especially for people hesitant to try traditional therapy, said Elizabeth D. Kilmer, PhD, a Seattle-based clinical psychologist, games researcher, and applied games educator. And because playing a game is intrinsically rewarding, participants may be more likely to stick with the intervention than with traditional group therapy, which research shows has a high attrition rate.

Therapists can reach additional patients with telehealth. Clinical social worker Heather MacGibbon leads Zoom TTRPG groups in which she plays as a character while a separate therapeutic game master (TGM) leads the game. Because the two are in different rooms, they can chat off-screen about how to meet players’ needs in-game. The TGM might message MacGibbon in the game if he wants to lead a player somewhere to help them deal with a particular issue, and the player is not picking up on hints. “It creates opportunities for us to not have to intervene directly, which can help people feel a sense of accomplishment and growth,” said MacGibbon.

Because it is so new, tabletop gaming as a therapeutic intervention is still vastly understudied. Yet advocates say TTRPGs show promise for treating a variety of symptoms across several populations. Here are some applications.

Whether a patient has an anxiety disorder or simply faces everyday worries, playing TTRPGs in therapy can help reduce anxious thoughts. In Connell’s groups with teenage girls, she helps players create monsters that represent their psychological struggles. In one game, Connell depicted anxiety as a small pixie that projected huge, scary-looking images. Creating images like this helped players reframe their thinking to acknowledge that while worries can feel real, they are often exaggerated and not grounded in reality—an observation they can take into their everyday lives.

The group structure of these games also helps players with social anxiety. When returning to the game after missing a week, one of Connell’s socially anxious players wasn’t engaging with other players. Connell paused the game so other players could reassure her and share their own struggles with anxious thoughts. This real-time correction helped all the players feel more valued and connected.

One evidence-based intervention for depression is behavioral activation, which encourages people to take actions that help improve symptoms. Attending psychotherapy inherently involves behavioral activation because it encourages taking action toward symptom improvement, but TTRPG groups can accelerate this process. Gaming groups tend to build rapport that encourages regular attendance, in contrast to traditional group therapy, where others may not notice if another group member attends or not. This rapport is facilitated by the fact that each character has at least one specific skill—for example, prowess with a weapon or a magical power—that the other players depend on, Jared Kilmer explained.

The long-term progress of the game also encourages a sense of accomplishment, which can be empowering for people with low mood, who may struggle to engage with activities they enjoy.

“To play a character that’s helpful and making meaningful contributions to the group can be empowering for players with depression,” said Connell.

TTRPGs can also help people identify and apply evidence-based coping tools outside the games. Connell’s participants create “depression monsters” weakened by players working together as allies. Collaborating to defeat the monster encourages strengthening social relationships to overcome depression symptoms, a skill players can use in everyday life.

For people with ADHD, therapeutic TTRPGs offer a chance to practice executive functioning skills and improve attention span. It’s one thing to sit quietly at a desk listening to a teacher talk about math or English. Listening to a game master describe details about the mystery you’re trying to solve is inherently rewarding, which encourages focus.

TTRPGs can also help players see the natural consequences of their impulsive or aggressive actions, which is often more effective in eliciting behavior change than a therapist’s advice, said Whittall. For example, one player who often provoked other players hit a town guard with a weapon for no reason. As game master, Whittall narrated the consequences of this action: All the players would be arrested. When the players next encountered a guard, another player said, “I don’t want to go to jail again.” That prompted the aggressive player to pause and refrain from impulsive behavior that could negatively impact the direction of the game.

TTRPGs can be a powerful intervention for supporting exposure response therapy (ERP), considered the gold standard for treating obsessive-compulsive disorder (OCD). One symptom of OCD is difficulty tolerating uncertainty: Individuals obsess over a particular worry, and then they perform compulsive behaviors to alleviate the discomfort of that anxiety. TTRPGs can help players tolerate ambiguity in a safe, supportive environment, according to Brett Merrill, PhD, a clinical psychologist and an associate clinical professor at Brigham Young University.

In the game, players with OCD have agency in decision-making—but much like in life, some results are left to chance. A player may attempt to avoid discomfort in the game, but a roll of the dice or other players’ decisions may cause them to experience it anyway. For example, a player may experience intrusive thoughts about accidentally harming another person. In the game, they may want to go back and check that someone they passed by wasn’t in danger, but other players may want to keep moving. The therapist can then, in real time, talk the player through their discomfort.

The game can also provide imagined exposures to obsessions, ultimately discouraging players from engaging with compulsions that perpetuate the OCD cycle. Grant Sparks, a licensed counselor in Atlanta, Georgia, creates scenes that include his OCD players’ obsessions. For example, one player in real life avoided potentially dirty or contaminated environments. In the game, Sparks led the TTRPG group through a dark, grungy cave filled with the remains of previous adventurers. While the player did not like walking through it, they persisted to meet the goal of the game. “By the end of the game, they realized the difficult situation wasn’t as awful as they thought, which carried over to real-life situations,” said Sparks.

Many people with post-traumatic stress disorder (PTSD) feel uncomfortable being emotionally vulnerable with providers who may not understand their experience. TTRPGs can provide a buffer for those resistant to traditional therapy, connecting them to support in a way that feels less threatening.

“Players can speak about their feelings through the character, which helps them slowly get engaged,” said Elizabeth Kilmer. For example, some military veterans were able to build relationships through weekly gameplay, eventually sharing more with other players and their therapist. After the therapy group ended, they started their own TTRPG group at a nearby base to build relationships between active-duty military and veterans.

The game can also provide opportunities to address PTSD triggers. One of Jared Kilmer’s players, a Vietnam War veteran who was triggered by storms, created a character that could summon rain or channel lightning. His fear became a source of power, eventually allowing him to re-contextualize storms in his daily life to reduce the intensity of the trigger.

Rigid thinking can be a hallmark of autism. But because TTRPGs are unpredictable, they encourage flexibility. Connell uses this aspect of the game to encourage players to identify areas of black-and-white thinking and try new things so they can see how rigidity might be holding them back from meeting their goals.

Creating and playing a character also provides a way to practice empathy, another area of struggle for autistic people. “We know from research that the more someone identifies with a fictional character, the more empathy they build,” said Connell. “By creating a character they see themselves in, players can concretely understand how someone else feels in different situations.”

TTRPGs are also a low-risk way for people with autism to work on social skills. William Nation, PhD, a clinical psychologist at Johns Hopkins University, often leads groups of college students on the autism spectrum. Many of these students seek support in helping to build friendships and romantic relationships. The game allows players to practice social skills in real time, with feedback from the therapist and other players. “It feels safer to practice in a game, knowing the consequences won’t feel as catastrophic as in real life,” said Nation.

Even for players without a clinical diagnosis, TTRPGs can serve as a “sandbox” for personal growth in different areas of life. Allison Battles, PhD, a clinical psychologist in Minneapolis, Minnesota, worked with a player who wanted to address a fear of rejection that kept them from expressing thoughts and feelings to others. “We created a character who knew a lot about history and storytelling, so the player and their character always had unique knowledge to contribute to different situations,” said Battles. “The more the player practiced vocalizing in the game, the more confident they became taking initiative in the game and in real life.”

Meanwhile, Christopher Carbone, a professional career counselor, cofounder of the Board Game Academics journal, and clinical psychology doctorate candidate in Staten Island, New York, used TTRPGs in a college career center as a way for students to explore different vocations and potential majors. A student interested in medicine could play an herbalist, for example, while a history major could play a historian.

One veteran Carbone worked with was unhappy with her job but lacked confidence to apply for a leadership role. The group agreed that she should lead their next adventure so she could practice heading up a group. By leading other players in a pretend adventure—often making decisions on behalf of the group—the player was able to build her self-esteem to the point where she felt deserving of a better job. She landed a new job a few months later.

TTRPGs can also provide an on-ramp for discussions about identity. In one of Merrill’s groups, a player chose to play as a changeling who could change form in the game. Another player interpreted the person’s changeling character as a symbol of LGBTQ identity, essentially “outing” the player to the group. “We had a conversation about why it’s so important not to out other people and how to develop empathy for people with different identities,” said Merrill.

Psychologists who use TTRPGs say the benefits are undeniable, but the intervention has limitations. For example, role-playing may be risky for people with identity inconsistency or more unstable mental health conditions such as dissociative identity disorder, said Sören Henrich, PhD, a lecturer in forensic psychology at Manchester Metropolitan University in England who studies TTRPGs. And for some, TTRPGs are best used in tandem with evidence-based modalities in traditional psychotherapy.

More research is needed about the use of TTRPGs in therapy in general, especially to delineate which components of the game are most therapeutically useful and for what clinical disorders and to determine clinical protocols for helping patients develop characters that lead to desired clinical outcomes and how to properly debrief after the games.

Despite its relative infancy, however, the use of TTRPGs in therapy appears to hold great promise. “This approach is so effective to help people reach their therapeutic goals that I almost see it as unethical to not use it,” said Connell.