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Doctors and child psychologists have long used play as a therapy, and there’s reason to think play can work as a therapy for adults.
Play provides a context where those with mental challenges like depression, anxiety, or attention deficit hyperactivity disorder (ADHD) can work through situations they find difficult to process and understand why and how they struggle with them.
This makes using a tabletop role-playing game (TTRPG) a unique yet promising method of improving mental health among kids and adults. The problem-solving opportunities and interpersonal collaboration involved in role-playing games have therapeutic potential for those struggling with mental illness or disability.
TTRPGs deeply engage a wide range of mental and interpersonal skills, providing a safe, nonjudgmental, imaginative, and fun environment where players can creatively work through their trauma or cognitive difficulties.
But are role-playing games proven effective in boosting mental health? Let’s delve more into the fascinating world of TTRPG and where it stands on mental health.
TTRGPs take the same spirit of the make-believe worlds that kids invent and add layers of structure and intricacy to them. Players have the freedom to create a complex, unique, even personal backstory for the characters they inhabit in a fictional world. They must collaborate and sometimes compete with other players to achieve their goals.
Role-playing games offer much freedom for the imagination to roam, but not everything is up to the player’s imagination. The Game Master or Dungeon Master, often shortened to GM or DM, is in charge of mediating the game and ensuring that the players’ actions conform to a set of rules. The GM plays the role of a facilitator and moderator during play. They have an intimate understanding of how the rules of the game and the laws of the supernatural or fantasy elements of the game world work.
Role-playing games typically have a very specific system of rules that controls what sorts of abilities characters have and what actions they can take. This system varies by preference and the kind of role-playing game being played. Still, it typically involves the use of dice rolls—including the famous 20-sided die—that generate numbers that players use to calculate how actions in the game play out.
But GMs also get to exercise their imagination. They are often responsible for designing quests and campaigns for the players to participate in, even developing entire fantasy worlds with original backstories and lore.
There are many prepackaged role-playing games with highly tested and well-thought-out rules. But ultimately, the style of play in a TTRPG is up to the players. Experienced GMs often develop new game elements or regulations called “homebrew” rules.
People have been playing pretend since the beginning of the human race, but it took a long time for this instinct for imaginative play to become a formal game with rules played solely for fun.
The first true tabletop role-playing game, Chainmail, came out in 1971. In 1974, Gary Gygax and Dave Arneson would derive its system into what has become the famous Dungeons & Dragons today. Tabletop games like Dungeons & Dragons, D&D for short, have their roots in early board games like Monopoly and the 1937 Jury Box, similar to the popular murder mystery game Clue. These games evolved from Victorian-era parlor games like blind man’s bluff and musical chairs.
Games of pretend combat are nothing new either. But until tabletop RPGs, they were always used as a real military training exercise for commanders. The Royal Game of Ur, Chaturanga, and Kriegsspiel are historical examples of this from ancient Egypt, sixth century CE India, and 19th century Prussia, respectively. While these games were meant to improve strategic skills on the battlefield, some were also compelling enough to play for their own sake.
Since the unveiling of D&D in 1974, TTRPGs have left a mark on popular culture, appearing in TV shows and movies and inspiring video games. As of 2020, there were over 50 million players of tabletop RPGs worldwide.
D&D has become so popular among tabletop RPG players that it’s almost synonymous with tabletop RPGs themselves. Other TTRPGs often use rules derived from Dungeons & Dragons, whose play and character creation systems are highly influential. Part of what gives this famous RPG its popularity is that players can adapt it to fit almost any playstyle, aesthetic, or fantasy setting.
Roll20, a popular tabletop RPG online resource, claims that 53.7% of its users played Dungeons & Dragons: 5th Edition in 2021.
Call of Cthulu’s appeal is its simplicity compared to the rules-heavy D&D. Usually set in the Victorian era, this RPG features ordinary people as characters, making it less intimidating to first-time players. It’s also perfect for fans of cosmic horror with its creepy, atmospheric setting.
Instead of dealing with complex bonuses and penalties that add or subtract from the dice rolls, Call of Cthulu uses a percentage-based system, leaving more room for newcomers to tabletop RPGs to have fun with their character creation process.
The same 2021 Roll20 report says 16.3% of its users played Call of Cthulu.
Pathfinder improves on Dungeons & Dragons in two ways: it offers more wiggle room for players to define their characters how they choose and allows for more development of a character’s powers and abilities. As a bonus, its character options are more inclusive of all genders and sexualities.
Around 3.4% of Roll20 users played Pathfinder in 2021.
On the other end of the detail spectrum from Call of Cthulu, there’s Warhammer, a game with such a fleshed-out and specific combat system that it’s widely known as being more detailed than Dungeons & Dragons, an already complex game. Its skill check and miscasting features add realism and more chances to fail, making it a more hardcore RPG for serious players who want a challenge.
As of 2021, 1.2% of Roll20 users were Warhammer players.
This RPG offers a different kind of setting from Dungeons & Dragons’ cloak-and-dagger, Tolkein-esque world. It takes place in an industrial, futuristic world with fantasy elements.
In 2021, around 0.4% of Roll20 users played Blades in the Dark.
Genre comes in different variations when it comes to TTRPGs. For example, the most predominant genre of story—which refers to the narrative told in the game—continues to be Action-Adventure. Other popular genres include Horror, Crime, Espionage, and Gothic.
There’s also the genre of setting, which depends on the conventions of the imaginary world in the game. In some cases, D&D is even referred to as a genre in itself because of its popularity and consistency in its setting assumptions.
Aside from D&D, other popular genres of setting include the following:
While using a tabletop RPG for mental health therapy is nowhere near widespread, there’s plenty of promising preliminary evidence to support the claim that using role-playing games for mental health has positive potential. However, there are also risks associated with role-playing games for children and teens with more vulnerable personality profiles.
Strong evidence of using role-playing games for mental health is the large body of work devoted to using play as a therapy for young children.
This kind of therapy rests on the principle that if a child is in a safe, judgment-free, imagination-based environment, they’ll be able to work through the same difficulties they typically experience in their day-to-day lives more consciously and deliberately.
The freedom of a play environment provides an opportunity to address these difficulties without fear or discomfort and can offer a chance to work around them.
No one’s mental illness is the same as someone else’s, and any therapy will address each patient’s disorder differently. TTRPGs can potentially treat various conditions; likewise, they pose certain risks to people with several types of vulnerable personalities.
A player with a mental disorder is encouraged to work through their mental challenges during a role-playing game.
For instance, players with problems verbalizing their emotions or intentions must work through this difficulty to collaborate with other players.
Someone with imaginative or cognitive delays or impediments may be encouraged by the nature of an RPG to exercise their imagination in creating their character or solving a problem during the game.
These players may find that an RPG presents a less stressful environment to address their problems because of its imaginative, hypothetical nature.
Studies have shown a wide range of mental health benefits from TTRPG games. Here are some of the most notable cases of RPG’s positive effects:
Games like D&D are well-suited to helping people with autism and ADHD, those with chronically low self-esteem, difficulty forming interpersonal bonds, and those with inhibited problem-solving and creative thinking skills.
Existing clinical literature finds that those who benefit most from Dungeons & Dragons as therapy are those with the most acute vulnerabilities, who find it hardest to find acceptance and accomplishment outside the context of play.
Role-playing games provide a context where communication with peers is based on a shared goal, and those who have trouble interpreting the emotions and intentions of others may find it easier to relate to others because of this. Those with pathological social inhibitions may find it easier to communicate in the context of a role-playing game because they are welcome to share their inner worlds without fear of judgment.
Loss of identity is the biggest risk that RPGs pose for psychologically vulnerable individuals. Role-playing games encourage players to delve into their imaginations and leave reality behind, and this can worsen the symptoms of those with an already compromised sense of self-identity.
Beyond those with acute mental challenges, role-playing games can benefit anyone experiencing trauma, social isolation, or anxiety. During the COVID-19 pandemic, the number of people interested in playing role-playing games for mental health increased even though the context for play was typically virtual.
While RPGs do foster social interaction, they can also encourage isolation. A person with autism or schizotypal personality disorder (STP) may find tabletop role-playing games to be a refuge from the kind of social bonding they have trouble building. They may have a few peers with whom they engage in RPG gaming without maintaining a full, open, and authentic connection.
They could instead use RPGs as a comfortable refuge from forming social bonds in the real world. This particularly applies to virtual RPGs played on a digital device while the player is physically isolated.
Those with a strong tendency to dissociate from reality or inhabit imaginary perspectives may find that role-playing games trigger this tendency. This tendency can cause stressful reactions in these players because they experience their character’s perspective so intensely that they have strong negative responses to adverse events in the game. They may even display symptoms similar to post-traumatic stress disorder (PTSD) because of this.
Those prone to violent outbursts and ideation might find that tabletop RPGs normalize these actions and feelings. This can lead to a small elevation in aggressive behaviors outside the game. Accordingly, players with this personality profile may want to consider this factor when seeking role-playing games as a therapy, perhaps using role-playing games without combat systems.
It can be hard to find ways to compel those with schizotypal personality disorder or autism to see the value in social bonds or develop new social relationships. People with STP deliberately avoid social interaction or bonding because it causes extreme discomfort, and those on the autism spectrum have trouble interpreting the emotions and intentions of others. However, TTRPGs encourage social bonding by giving players a shared goal and purpose and making cooperation and communication necessary to win the game.
TTRPGs offer a sense of accomplishment as players complete goals and move through storylines. This raises self-esteem and provides a low-stakes environment where failure does not have a strong or negative effect on a person’s sense of self-worth. Someone who has difficulty asserting their intentions and desires will find a role-playing game to be an environment where they can safely express these aspects of themselves.
RPG storylines also often involve overcoming challenges, and a player can gain a sense of personal growth through inhabiting a character in the game. This has a high potential benefit for those with disorders like dependent personality disorder (DPD) who struggle with asserting themselves.
Attention deficit hyperactivity disorder (ADHD) causes difficulty in finding any one task engaging or pleasurable enough to remain focused on it. Surprisingly, those with ADHD are often also capable of razor-sharp focus, the flip side of an inability to regulate one’s attention. Role-playing games can be deeply absorbing, and people with ADHD may find this freeing because it provides an outlet for their attention. Another effect of ADHD is an increased difficulty navigating social interactions, and Dungeons & Dragons can provide a context for growth in this area.
Those with cognitive delays may find tabletop RPGs challenging and deeply rewarding. A role-playing game offers a safe environment to work on these skills for players who find arithmetic, decision-making, or plot-related elements hard to understand. Games like Dungeons & Dragons can have complex rules, so other role-play styles may be better suited to this personality profile.
Many institutions have recently used D&D therapy for people with mental conditions.
Licensed therapist Adam Davis co-founded a therapy group called Wheelhouse Workshop, which uses the iconic board game as a tool to improve social issues among children. The Scout Association—the largest Scouting organization in the UK—has also officially partnered with D&D, introducing Scouts to the world of role-playing so they may build confidence and other skills through fantasy storytelling.
According to a 2021 study, while D&D leads to higher levels of creativity and empathy, many therapists still seem reluctant about using it as a therapeutic intervention due to two reasons:
While D&D, as well as other TTRPGs, provide promising benefits to mental health, there is a need to apply several practical implications to make the intervention successful, which include the following:
Being specific and outcome-oriented when using D&D as therapy
Role-playing games like D&D are also known to improve the mental health of children and adolescents in nonclinical settings.
According to this 2022 study, D&D players can meet real-world needs through symbolic in-game interactions. The role-playing game also helped decrease the players’ social anxiety and cope with stress and internal conflicts.
The findings show how parents and their children suffering from mental and social issues can benefit from playing D&D and other TTRPGs. However, it’s important to note that while many cases support the game’s positive effects on mental health, TTRPGs should not be a substitute for treatment. There is still much room for further study into role-playing games as a therapy, and the jury is still out on their exact effects on mental health.
Parents are advised to monitor their children while playing and make sure they relate well to themselves and others during play. If they encounter difficulties while playing, it’s best to use the moment as an opportunity to help them through it in a gentle and nonjudgmental manner.
Role-playing games have a high potential for benefiting those with mental illness. But to work as a treatment, they must be implemented carefully with close supervision, with an awareness of the potential risks and benefits for a particular player. The same aspects of RPGs that are beneficial can also cause harm—inhabiting an imaginary reality can either be a way toward social bonding or a way of escaping it, depending on how players relate to each other during a play session.
They can bolster a player’s assertiveness and self-identity through exploring the imagination and offering accomplishment in a safe setting, or they can be a way to avoid exploring avenues of self-making by avoiding achievement in reality.
Ultimately, RPGs remain an under-examined therapeutic tool that, if used correctly, can offer great benefits to those with psychological conditions.