How to Engage with Gamers in Therapy

Last month, I published an article evidencing many, many ways video games can help with diagnosed mental health conditions such as depression, schizophrenia, addictions and more. I wanted to include a section on engaging with gamers in therapy, showing how and why people should talk to their therapist about playing video games and vice versa. When I realised I had to cover 100+ sources in the article, I knew I would sadly have to shelve this topic for another day.

Well, the day is here. In this article, I aim to achieve two things:

1. For people who play video games, I will evidence why you shouldn’t be ashamed or embarrassed to admit to your therapist that you play video games. This can be helpful for letting them get to know you and can even be used in treatment planning, which brings us to our second point.
2. For therapists and clinicians, I will discuss how to engage with people who play video games and will share successful case studies of how stories clients shared about playing video games led to positive outcomes in their treatment plan. This section will also be helpful for non-therapists as you’ll get a peek behind the curtain of treatment planning.

As usual, there will be a summary at the bottom if you don’t wish to read everything. Now, let’s begin!

Contents

1. 1. Gamers: Engaging with Your Therapist
      1.1. Getting to Know Your Friends
      1.2. Getting to Know Yourself
      1.3. Getting to Know Your Therapist
   2. Therapists: Engaging with Gamers
      2.1. The Power of (Online) Friendship
      2.2. Your Are Your Avatar (and vice versa)
      2.3. Homework is…Fun!?
      2.4. Gimme Those Recs, Doc
   3. Summary
   4. Credits
   5. References

Gamers: Engaging with Your Therapist

Around 13 years ago, I was asked by a psychologist during my initial assessment about my hobbies and interests. I completely hid my love of video games for two reasons. Firstly, I was aware of how video games were constantly used as a scapegoat for life’s problems. I feared a mental health professional having a eureka moment and blaming all of my problems on video games rather than my constant health issues or overwhelming loneliness. Secondly, I was just simply embarrassed. Instead, I forced small talk on watching TV and the funny robot from Futurama. They didn’t get to hear about my online friends, my love of creating guides and content for gaming communities, how I felt that video games were a creative outlet for me in a world where I wasn’t randomly selected to play an instrument at school, the list goes on.

Apologies if that sounded overly indulgent, but I hid my love of video games in therapy and honestly regretted it. I want to take this regret and use it to inform and empower others not to be ashamed of who they are and what they enjoy. So let’s get into the benefits of being more honest with your mental health care provider.

Getting to Know Your Friends

To start, I would argue that gaming is more social than ever. Whether it’s the plethora of free to play online games, the award-winning free trials of MMORPGs (sorry, I’ll stop), or even the ability to have thousands of gamers at your fingertips with services like Discord, chances are you’re talking to at least one other gamer throughout your day.

This is where some of the fear and embarrassment from my younger self kicks in. When I was growing up and digital friendships began to evolve, there was earnest debate surrounding whether these people were ‘real friends’. My teenage opinions were often ignored during this debate of the grown ups, but I now get to weigh in on this debate fully equipped with academic research.

Not only are our gaming friends ‘real friends’, but they can sometimes be more valuable sources of comfort and support than those we spend time with offline. In a study of online role-playing game players, 39% admitted that they were able to talk to their online gaming friends about problems they were too scared to talk to people offline about [1]. In a more recent study of World of Warcraft players [2], it seems that being part of a guild is not only helpful for learning more about the game, but is related to statements like “When I am feeling down there is someone I know through World of Warcraft I can lean on”.

With this in mind, I feel that a natural conversation with your therapist could include talking about gaming, talking about gaming friends, asking about what you all talk about together, and then having a natural segue into talking about what it is you confide in these friends.

Getting to Know Yourself

Another reason why you can benefit from being honest with your therapist involves learning more about yourself. Especially during appointments such as your initial assessment, your therapist is going to want to know more about you – what you do, what you enjoy, what you like. As you’ll see in the upcoming therapist section, this can be a lot more than just ‘I like Futurama because of the funny robot’, it is an opportunity to share with someone why you like things and what you get out of them.

This is where I have to admit to inserting my own little agenda. I am a huge believer in journaling and allowing yourself space to question things about yourself and your life. Prior to a therapist asking you about your interest in video games, you could sit down and ask yourself about your interest in video games. It could be something as simple as opening up a Word document or a notepad and answering prompts such as:

I play video games because…

What I like most about video games is…

What I find most fulfilling about video games is…

My fondest memories with video games are…

This is just a selection of prompts that can get your brain jogging, for which you can read more here. Giving yourself a few minutes to think about your interest in video games can help you get to know yourself and your interests a bit better while also helping to prepare helpful responses for your therapist, and we’ll see more on how this information will be useful in the therapist section.

Getting to Know Your Therapist

Before I move on to the therapist section, I want to acknowledge that what I have talked about thus far is an idyllic scenario where your therapist is a perfect fit for you. There may of course be some teething problems at the beginning of the relationship, or something more challenging to your relationship such as having negative opinions towards video games. In the event of this, you can always turn to some good old academic research to calmly state your case. Some examples include:

“Sitting at home playing video games is stopping you from making friends”: You’ll have to reflect on this one for yourself. I have often seen people play games and play online when their real-life circumstances make it difficult to make friends. However, I have come across the occasional person who deliberately limits their socialising to stay home and play video games. It is important to discuss your own social history, attempts you have made to connect with others, and even discussing how supportive online friendships can be with the studies cited in this article [1-2].

“Video games are bad for you”: This is quite a sweeping statement for technology that can help with physical and mental health. This could also be an opportunity for you to reflect on your own experiences with video games. Do you think they have been bad for you? Can you provide contradictory evidence (e.g. supportive online friends) to counter this claim?

“You could be addicted to video games”: I would recommend careful consideration of this claim. You can view the diagnostic criteria for Gaming Disorder and the proposed diagnostic criteria for Internet Gaming Disorder here and here respectively. However, clinicians will/should place the greatest emphasis on how disruptive video games have been to your life. There is a difference between dropping out of college because you couldn’t stop playing League of Legends long enough to attend your lectures, and dropping out of college due to overwhelming anxiety and now playing League of Legends to pass your day in between job applications. Imagine diagnosing someone with depression as having ‘Bed Syndrome’: the behaviour (staying in bed) receives more clinical attention than the underlying causes (depression). If your therapist is concerned that you may be addicted to video games, you can have a discussion about the diagnostic criteria and how much you feel it applies to you, including whether you think an instance of ‘Bed Syndrome’ might be happening here in terms of your own mental health.

“Video games contribute to violence and aggression”: There are way too many sources that contradict this to cite in one short paragraph. Entire evidence-filled books have been written about this topic [3], but if you would like to equip yourself with some interesting pieces of information, you could say that researchers have found that you would need to play video games for 27 hours per day for it to have a tangible impact on aggression [4], and data analysis of hundreds of thousands of adolescents found that silly things like going on family holidays and even having female friends had a stronger relationship with violence than playing video games. You could even encourage them to assess their own media biases, as media reports are eight times more likely to blame video games for violent acts if the perpetrator is white [5].

Therapists: Engaging with Gamers

In this section, I will give suggestions to therapists on how knowledge that their client plays video games can be used for good. I will fully disclose that my doctorate is in mental health research and I am not responsible for directly delivering mental health care. The suggestions provided here come from a combination of reading academic research, reading books written by therapists on this topic, and reviewing psychiatric case notes as part of a prior research role.

The Power of (Online) Friendship

I’d like to begin by talking about the concept of online friends. In the previous section, I mentioned that talking about online friends could be an opportunity to ask if there are any topics that they talk to their online friends about that they have difficulties disclosing to others. I’ll just reiterate that this would be a helpful thing for therapists to do as it is quite a natural segue into topics that the client may have trouble discussing.

I appreciate that while online friendships may be a helpful source of support to some, they can be a bit…shallow for others. The extent of some voice chats may not go further than shouting out enemy locations on a map, but they could. I reviewed case notes related to a very introverted person who played a lot of online video games. Without going too deeply into their history, their therapist set them some honestly very nice homework tasks: 30 minutes of voice chatting outside of the game setting. This homework task always stood out to me because I thought it was very smart and considerate. The young person wasn’t being punished for being shy and introverted and primarily having online friends. Instead, they were encouraged to practice conversational skills in an environment that was natural to them that they could later apply offline. They practiced conversing with others and they got to deepen their friendship with others – everyone wins!

You Are Your Avatar (and vice versa)

Our relationship with video games can help reveal aspects of ourselves that our therapist can work with. I can think of no better example of this than the case study of Dean from Dr Bean’s book Working with Video Gamers and Games in Therapy [6]. Dean was a shy teenager with low self-esteem who had difficulties speaking with others, but was the complete opposite when it came to video games. He was a guild-leading Warrior in World of Warcraft, a class that can be quite anxiety-provoking in itself depending on how it’s played.

Dr Bean’s approach upon hearing this was twofold. Firstly, he worked with Dean to show that he already had the skills he thought that he was lacking in. Struggling to talk to new people? But you regularly welcome new guild members and enjoy getting to know them. Having difficulties asking for help at school? But you need to rely on others for help in World of Warcraft. You can only have two professions in the game, so you’re eventually going to need help with potions or repairs or food or gems or other things depending on the professions that you pick. The problem lay in Dean possessing skills but being unsure of how to transfer them offline, which Dr Bean assisted with.

Secondly, Dean’s self-esteem was preventing him from doing challenging things like asking someone on a date. This is a terrifying prospect for most people, but Dr Bean was able to take advantage of Dean’s experience with video games. In one of their appointments, they roleplayed how Dean’s avatar, a confident guild-leading Warrior, would approach asking out a girl that he liked. As you can imagine from the first approach, they worked on how he could take skills he already had (being kind and considerate and courteous to others) and apply them to offline scenarios.

This case study had an ending that never fails to make me smile. Not only did Dean have the confidence to ask for extra help from his teachers (which he received), but he was able to ask his romantic interest out on a date and she said yes! In an offline world where Dean was shy and not very social, Dr Bean got to know Dean and how he interacts with others through playing online video games. Dr Bean was able to profile the wonderful skills that Dean had all along, encouraging him to pursue his offline interests that led to wonderful results. I wholeheartedly encourage other therapists to consider this case study and the power of understanding your clients through their online interactions.

Homework is…Fun!?

As mundane as they seem, questionnaires are a valuable tool for therapists. They are not only well-researched tools that help identify mental health symptom clusters, but can be used to track treatment progress across appointments. Clients will either get used to or become bored of these regular questionnaires, but you can use this to have a little fun while also broadening their gaming horizons.

Something that I enjoy recommending is the Gamer Motivation Profile, a questionnaire that helps people identify what type of gamer they are, what their main gaming motivations are (social, exploration etc.), and even recommends games based on their gamer profiles. In case this is sounding like a Buzzfeed quiz that you would take during lunch, this questionnaire was empirically developed using data from over 850,000 gamers [6].

If your client talks about enjoying video games, you could recommend the Gamer Motivation Profile as a fun homework task to do for next time. This simple act has a number of benefits:

1. As I mentioned in my article on how video games can be useful in therapy, therapists can struggle to get clients to complete homework tasks. After all, why would they voluntarily do something called ‘homework’? This helps reshape homework tasks as something that can be interesting, informative, and won’t always be seen as a chore.
2. The Gamer Motivation Profile would not only help them to learn about themselves, but would also give them video game recommendations based on their answers.
3. Therapy can be stressful, and this small thing can ease the stress of an upcoming therapy session by giving them something fun to talk about next time.
4. By recommending this questionnaire, it shows that you listen to them and are considering them as a whole person, not just as a symptom cluster that meets the diagnostic criteria for a mental health disorder.

Taking a few minutes to recommend this, then taking a few minutes to talk about the results in the next session is a great way to build rapport, reshape the idea of a homework task, and learn about some fun video games that they can play!

Gimme Those Recs, Doc

In this section, I’ll be continuing on with the themes of game recommendations and respecting the uniqueness of the client. While I previously mentioned that my younger self was too embarrassed to admit to playing video games, it can be just as scary as an adult to admit to playing them. You’re not supposed to be playing games at your age, you’re supposed to be watching Netflix! Thankfully the stigma has been decreasing in recent years, and one of my kind Patrons had some lovely and encouraging words to share about having a therapist who raided (completed challenging group content) in World of Warcraft:

My therapist having raided let me attach less shame to my experiences: I knew she could understand the validity of online friendship and teamwork, and the feeling of ‘getting lost’ in time spent in-game. Normally I’d have to set up a bunch of metaphors with people in the hope they could make a connection that let them empathize, but having someone who could relate was really nice.

 

So if you’re the type of therapist who reads gaming news with their coffee, this one’s for you.

Talking about the meaningful experiences that video games can provide seems almost redundant at this point. Spiritfarer was a beautiful game that helped me process the loss of my childhood dog, and a small-scale study of Spiritfarer players showed that it could actually help others process and reframe their grief too [8].

Many, many articles have been written on how games such as the platformer Celeste can be a meaningful and contemplative experience for working through gender dysphoria. Games such as The Jackbox series are an easy and accessible way to build hilarious memories with friends, and could even be recommended to clients with online friend groups to help them practice speech skills in a fast-paced environment. For those slightly younger, I mentioned in my previous article how moderated Minecraft servers can be a safe environment for socialisation and expression, helping clients to meet new people and express their creativity. Even health-promoting games such as Ring Fit Adventure and Pokémon Go can encourage us to become more active [9-10], and these could be perfect for clients who are unhappy with their fitness levels and would like to be more physically active.

I have to stress that I am not trying to say that playing video games can cure clients of whatever ails them. Instead, you get to use any knowledge of video games that you have to strengthen rapport, share recommendations, and use these recommendations to learn more about them and to encourage dialogue. For example, you could talk to someone who played Spiritfarer about what characters they bonded with the most, how the game made them feel at certain points, and whether their perspectives on grief and loss have changed.

Think of the chain of events that led to Dean getting a girlfriend. He talked to his therapist about playing World of Warcraft, how it made him feel, how he felt different from the offline world, and his therapist reminded him of the skills he had all along.

Wonderful things can happen just from simple conversations about video games, sharing our love of video games, and talking about how they make us feel.

Summary

• Talking about playing video games gives clients an opportunity to talk about their online friends, and research shows that online friends are a great source of emotional support. This could open up dialogue with your therapist regarding what you confide to your online friends.
• As your therapist might ask you questions about your interests in video games, this could be an opportunity to reflect on your love of and history with video games using journal prompts. This can help you learn more about yourself and what attracts you to the hobby before your appointment.
• Unfortunately, there may be a scenario where a therapist does not approve of playing video games. Advice and research is provided for scenarios where they feel video games promote loneliness, poor health, aggression and addiction.
• Therapists can take advantage of clients with online friends by promoting social activities such as voice calls and even playing social communication games such as the Jackbox series.
• Clients who roleplay and/or play games where they are invested in their avatar have interesting stories that can be a gateway to skills and qualities that they have, but haven’t exercised offline. A case study of Dean is provided, a shy teenager who was encouraged by his therapist to ask for academic help and to even ask a girl out by showing that he had confidence and social skills as his guild-leading Warrior in World of Warcraft. The story had a happy ending!
• Therapy can be accompanied by homework tasks which unfortunately can have low completion rates. Therapists can recommend fun homework tasks such as taking the Gamer Motivation Profile, a questionnaire that tells users what sort of gamers they are, what motivates them to play video games, and even provides video game recommendations. This can give the client something to look forward to talking about in their next appointment, builds trust that they are being listened to, and reinforces the idea that homework tasks aren’t necessarily boring.
• It can be embarrassing to admit to playing video games in a professional environment, but knowledge and experience with video games can not only put clients at ease, but can lead to clients being recommended video games with meaningful experiences such as Spiritfarer that can be talked about in future sessions.

Credits

A big thank you to DECosmic for designing my header image and to LoopyGc for drawing the header art.

This hard work would not be possible without the support of my wonderful Patrons. I would particularly like to thank my Platinum Patrons: Albert S Calderon, Kyle T, redKheld, Hagbard Celine, Aprou, Austin Enright, NotGac, Shaemus, Joey Rodriguez, DarrenIndeed, Thomas Meszaros, Dr. Jhin, Mulgar, Tobias Svensson, RK_Rammy, John Bauman, and Gamma Ray Garrett. Thank you!

 

References

[1] Cole, H., & Griffiths, M. D. (2007). Social Interactions in Massively Multiplayer Online Role-Playing Gamers. CyberPsychology & Behavior, 10(4), 575-583.

[2] Zhao, X., Obst, P. L., White, K. M., O’Connor, E. L., & Longman, H. (2021). Network analysis among World of Warcraft players’ social support variables: A two-way approach. Journal of Gaming & Virtual Worlds, 13(3), 249-264.

[3] Markey, P. M., & Ferguson, C. J. (2017). Moral combat: Why the war on violent video games is wrong. BenBella Books, Inc..

[4] Ferguson, C. J., & Wang, J. C. (2019). Aggressive video games are not a risk factor for future aggression in youth: A longitudinal study. Journal of Youth and Adolescence, 48(8), 1439-1451.

[5] Markey, P. M., Ivory, J. D., Slotter, E. B., Oliver, M. B., & Maglalang, O. (2020). He does not look like video games made him do it: Racial stereotypes and school shootings. Psychology of Popular Media, 9(4), 493.

[6] Bean, A. M. (2018). Working with video gamers and games in therapy: A clinician’s guide. Routledge.

[7] Yee, N., & Ducheneaut, N. (2017). Gamer motivation model. Retrieved June 2, 2022 from https://quanticfoundry.com/#motivation-model

[8] Eum, K., Erb, V., Lin, S., Wang, S., & Doh, Y. Y. (2021, May). How the Death-themed Game Spiritfarer Can Help Players Cope with the Loss of a Loved One. In Extended Abstracts of the 2021 CHI Conference on Human Factors in Computing Systems (pp. 1-6).

[9] Althoff, T., White, R. W., & Horvitz, E. (2016). Influence of Pokémon Go on physical activity: study and implications. Journal of Medical Internet Research, 18(12), e6759.

[10] Khamzina, M., Parab, K. V., An, R., Bullard, T., & Grigsby-Toussaint, D. S. (2020). Impact of Pokémon Go on physical activity: a systematic review and meta-analysis. American Journal of Preventive Medicine, 58(2), 270-282.