AMA About Clinical Psychology (and RPGs!)

[CaptainKobold]

Hey Booters!

I'm not sure whether there will be interest in this, but seeing that the AMAs have kind of slowed down, I thought I'd pop on here and throw something up to hopefully unplug the dam.

My Credentials:
MA in Psychology
Current PhD Student in Clinical Psychology at a largely Cognitive Behavioral University in the US
Work in two in-patient mental health settings (combined time ~2 years)
Work with Elementary school children presenting with ASD, Selective Mutism, Anxiety, etc.
Specific work with Twice Exceptional children
Runs an RPG group with focus on social skill building
Beginning research on social skill building through RPGs
About 12 years of playing RPGs (largely as the GM)

Needless to say, there are a fair amount of details I can't discuss (and I'll be following appropriate ethical guidelines), but feel free to ask away!

[Magmoo]

Are there any good guidelines for deciding when roleplaying has started to cross from healthy fantasy/expression/release into unhealthy?

[zircher]

Know any RPGs that you would classify as unhealthy regardless of the age of the players? (I imagine Fatal would be high on the list.)

[Addicted2aa]

How much can therapy actually help a person overcome issues? How bout medication? What's your view on the idea that majority of people need therapy?


On RPGs


Do you believe training in psychology will help GM's run games, both in managing out of character social tensions and in creating games more targeted towards their players desires? If so how much training do you think is valuable vs how much is overkill for increasing skills in a hobby?

[Infrared]

Hey, thanks for taking the plunge!
Here's a couple from me:

- How's your research coming about, without getting into great detail?
- RPGs in some form or other have been used in therapy for years, as far as I understand. Can you recommend any good recent studies or review papers on the topic?

Thanks!

[CaptainKobold]

Thank you for the questions! I just wanted to let you know that I haven't forgotten about this, I just ended up being surprise-internetless over the weekend. Because of that, I've got some of the responses, but not the last one for Infrared (sorry, Infrared! Later today! I promise!)

In any case, here is the patented Captain Kobold Wall-of-Text. Feel free to let me know if there's anything I can clarify, if you have other questions, or whatever else!

Are there any good guidelines for deciding when roleplaying has started to cross from healthy fantasy/expression/release into unhealthy?
Magmoo, this I think is a very interesting question because of it's implications societally. We've all heard about the Satanists in the Steam Tunnels and we've all likely met someone who seemed just a bit too involved in the splatter from their sword-swing.
That said, the vast majority of people could likely play RPGs as much as they would like and never pass into something unhealthy. Instead of viewing this as a single group, I'd like to formulate it as two types of problem that could actually arise.
The first would be people with a tendency towards behavior that is dysfunctional. This likely isn't what you are asking about, but I figure I can address it anyway. There are people who, for a multitude of reasons (that I can speak more to if people are interested) act in ways that are violent, harmful, or hateful towards themselves or others. These people will demonstrate these sorts of tendencies in multiple areas of their lives and RPGs are no exception. If someone is (as a slightly over-the-top example) very volatile (such as someone with borderline personality disorder), they may find the social stresses and situations involved in playing a roleplaying game very difficult to manage. I've seen in-patients throw punches over Sorry or Connect Four and there's no reason not to believe that couldn't also apply to roleplaying! That said, the roleplaying game hasn't caused this to happen.
The /real/ question is probably for a less dysfunctional population. This can be summed up with a little phrase Erikson claims Freud used (but didn't! History fact of the day!): To be mentally healthy is the ability to love and to work. I would say that roleplay has moved to unhealthy expression when the game begins to interfere with their life and they are experiencing distress related to this. Signs of this would be things like failure to take care of basic tasks they need to do in their life, separation from non-roleplaying fans, or fantastical behavior that interrupts their ability to interact with non-roleplayers. If someone begins to experience this, it likely would be good for them to branch out and rebalance their life, but I wouldn't suggest any sort of cold-turkey approach. Roleplaying games remain, in my opinion, mostly safe for people to play.

Know any RPGs that you would classify as unhealthy regardless of the age of the players? (I imagine Fatal would be high on the list.)
D&D 4th Edition. Yuk, yuk, yuk.
(No seriously, I'm cool with 4e, but couldn't help the setup.)
I think you are right to highlight age of the players as an idea behind this, so I don't want to get too distracted by Kids and Gaming as I think this will be a bit of a lengthy response already. I'm a bit long winded.
Two categories on this one also, I think.
Objective Horrific Games:
There are certain games that are less systems that people would want to play and more disjointed manifestos of obviously troubled people. I would put F.A.T.A.L. pretty firmly into this category, along with the Racial Holy War and HYBRID. These are games essentially only in form and have more to do with people propagating hate-speech. In the same way that I wouldn't recommend that anybody binge-watch Klu Klux Klan videos, these are media that encourage hate.
This may seem like a somewhat unscientific criticism of these games, so I want to go a little more in depth here without belaboring the point. I don't believe that playing F.A.T.A.L. will turn someone into a crazy sex-maniac who goes around killing people for fun. There have been tons of studies on media violence and frankly the data have been so discrepant that it's difficult to be objective. My own personal opinion is that while children frequently show tendencies to learn violence socially there is not sufficient evidence to suggest that otherwise psychologically healthy adults cannot parse the differences between the real world and fiction pretty well. The reason that I /do/ recommend people stay away from these games is a slightly more subtle one.
When someone interacts with hate speech, they almost always experience negative emotions (either agreement and anger with said hate speech or anxiety and pain). These results are fairly consistent in short interactions with hate speech (short videos, images, brief interactions). Now consider taking that brief interaction and spread it over reading an RPG tome, creating your characters (with the F.A.T.A.L. system, my understanding is this takes several hours), and then playing (a 4-8 block chunk of time). Through all of this time, the player is experiencing hate speech which is almost certainly harmful to their emotional state. So why do that? Instead, it is likely psychologically healthier to play in games that work within, question, or otherwise interact with an expression of their values. (Values-Based psychological treatments like ACT are something I'm especially focused in and would be happy to expand upon as well).
Specific Interaction of RPG and Player
Can you believe I'm only half-way through your answer? I'm afraid I'm a wall-of-texter.
There are a lot of games that the appropriateness of it has less to do with the overall and more to do with specific experience. In these cases I think the the best way to approach it is how the players will interact with the world and what their specific triggers may be.
(Aside: Yes, tumblr is full people talking about trigger warnings. Yes, I think people take this more seriously than they strictly need to. Still, people with traumatic experiences in their past can have very strong reactions to certain content.)
These would be games that I don't think are specifically 'bad games' for all of society, but the age of the player doesn't necessarily provide a protective factor against it's content. Instead of breaking down every game I can think of that has potentially triggering content, I'll take one example and dig it out a little bit. In this case, I'm going to use Unknown Armies (though many of the same points will stand true for Vampire: The Masquerade or Lovecraftian Horror things)
Players Who Are Victims: The idea of producing magic or power through sexual violence could be a potentially troublesome theme. One could certainly play a game in these systems without sexual violence in them, but they are codified in the book. Because of that, people with traumatic backgrounds may experience strong negative emotions. This would really be true regardless of whether the character exploring these themes is an NPC or a PC.
Players Who Are Aggressive: This same idea goes the other way on this as well. If someone has sexually violent tendencies, playing them out in a group environment where everyone talks about how much more powerful they are is likely not good for them. Ideally I'd like to believe that these kinds of characters make excellent NPCs and bad PCs, but the the fact of the matter is that there are players who would enjoy playing a rape-powered mage. While I don't think that the game alone would be something that would be terribly harmful for someone without these sorts of aggressive tendencies, it's probably not good for them to glorify it.
Players With Mental Disorders: This kind of draws into the portrayal of psychological disorders in games. Games that have Dark Themes love looking at ‘insanity’. Usually things are simple enough that they can avoid being overly specific to people’s situations, but there are certainly exceptions. Someone who is attempting to deal in their regular life with a psychiatric disorder playing a psychiatric disordered character may essentially be asking for their symptoms to intensify during the sessions (expectancy is a powerful thing!). On the other hand, if Bob across from you is pretending to be schizophrenic that could be very painful if you are personally suffering from schizophrenia and doing everything you can to control it.

It almost comes down to Know Your Players. I don’t think there are any games that will turn a ‘regular’ person into Jack the Ripper, but there are definitely situations in games that can make lots of players feel deeply uncomfortable in ways that are probably worth respecting.


How much can therapy actually help a person overcome issues? How bout medication? What's your view on the idea that the majority of people need therapy?
How effective therapy is depends very much on the presenting problem of the patient, the treatment modality selected, and how willing the patient and clinician are to work for results. That said, with proper motivation and an appropriate treatment, therapy is far more effective than most people understand for most problems. At the risk of setting off a psychological orientation wank (Edition Wars, Psych Style) I’m going to take a moment to talk about the APA and ESTs.
The APA is the major governing body of psychology and is responsible for deciding who gets to be a psychologist and who doesn’t. In addition to this, they attempt to provide resources for psychologists and other therapists in deciding which treatments are effective for which diagnoses. One of these resources is their list of Empiracally Supported Treatments (ESTs, which are also called Empiracally Based Treatments or EBTs) for various disorder. What the APA does is look at the research and determine whether a treatment has been demonstrated through direct, scientific clinical research (with replications!) to be an effective treatment for a population. What this means is that there is basically a list that a psychologist can access and look things up. A patient comes in with specific phobia and the psychologist can instantly know that CBT with a focus on graduated exposure is probably the way to go. This gets slightly muddled by the fact that most psychologists specialize in one kind of treatment for one kind of patient; I’ve met a clinician who works with female agoraphobics with combined OCD over the age of 65. Because of this, clinicians make frequent referrals to people who treat whatever the patient is coming in with.
What does all of this mean? There are treatments that you could do forever and they will never get results. Woody Allen brags of having stuck with his treatment (psychoanalytic treatment for neurotic anxiety) for years. On the other hand, specific phobia is empirically supported for graduated exposure (6-12 weeks of treatment once a week) or flooding exposure (1 long, intensive treatment). There is evidence for Cognitive Behavioral Therapy (CBT) working well for most disorders with treatment time listed in months, not years. The Third Wave of Psychology (Acceptance and Commitment Therapy [ACT] and Dialectical Behavioral Therapy [DBT] hold promise for some treatment resistant populations. Truth in advertising, I’m at a highly Cognitive Behavioral University and my focus is going to be in ACT, so the fact that I support those approaches shouldn’t be a huge surprise.

Medication!
Here’s an awkward truth most people don’t know about psychological medications. We aren’t really sure why a lot of them work. Sure, Selective Serotonin Reuptake Inhibitors (SSRIs) keep sereotonin in your system and help with depression or anxiety, but Lithium? Who the heck knows. Most of the early medications (which more modern treatments are based on) were developed either by accident when treating something else or in a really slapdash way.
That said, I did say we aren’t sure why they work. Many of the drugs that exist are very effective for doing what they say, stablizing or lowering essentially chemical responses. Most psychologists view this as only half of the picture; medication has consistently proven most effective when combined with therapy. Medication can never really ‘cure’ someone of a psychologist disorder, rather it can provide abatement that allows the patient to learn skills, practice strategies, and get themselves to a more comfortable place in their life. There are quite a few therapists who actually discourage the use of medication, but I’m not one of them. There are many disorders that are so disruptive to people’s lives that the medication is all but necessary.
There are, of course, a couple of disorders that essentially require life-long medication. Management of schizophrenia is very difficult to do without consistent medication use.

Alright, so if you’ve made it through those walls of text, I’ll see if I can answer that last question. This may be a little bit more of a personal opinion than anything else, but I’ll see if I can bring in some Hard Science as well.
My take on it is that there is a minority of people who essentially need therapy. These would be people who lack the skills to manage their lives and the individual challenges that they face. Some of these people do get treatment (in-patient or out-patient) and it makes an enormous difference in their lives. Others who don’t can end up involved with drugs, violence, death, or simply lives that are far more difficult than they need to be. Therapy can be the thing that prevents these people from destroying their lives.
That said, I think there are very few people who wouldn’t benefit at all from therapy. On a purely humanistic sort of level, there’s something to be said for talking to someone who wants to understand you and isn’t making judgments against you. Additionally everybody has stresses in their lives that could potentially be fixed or simply dealt with better through improving of coping skills. One of my supervisions has included a large amount of meditation and introspective work which over the time I’ve been involved in it has probably made me more able to deal with my stresses. Everybody can benefit from new tools in their life toolkit to help deal with problems better.
Also, if you’ve never tried meditation, I highly recommend it.

[zircher]

Wow! Excellent answers, thanks!

[CaptainKobold]

Thank you very much! I'm happy to be able to ramble on about these things. I can, as is probably obvious here, talk about psychology and games all day long! I've got the next couple of questions here, so if anyone else has any other questions feel free to ask!

Do you believe training in psychology will help GM's run games, both in managing out of character social tensions and in creating games more targeted towards their players desires? If so how much training do you think is valuable vs how much is overkill for increasing skills in a hobby?
I definitely think that training in psychology has helped me in many of my social interactions. If you really pay attention in the training, take things to heart, and apply them you almost can’t avoid getting better at dealing with social problems around you. I also definitely think that my training has helped me in GMing games, especially with the child-group that I’ve been running. With them, management of out of character social tension is obviously more difficult than my group of adult friends who mostly can manage themselves! I also think it has helped me with targeting games, though I’ll admit I have slightly less valid data on this as my psychological training has been happening as I’ve grown steadily older and more mature.
(Psych Fact! The fore-brain (where most of logical reasoning, consciousness, and decision making seems to be located) is still developing until about age 25!)
My own good experiences aside, I think it may be something more like a side benefit than something people ought to be attempting to get to up their game. Honestly, the amount of work that goes into the whole psych-degree just is more than it’s probably worth for the benefit. That said, there are some pretty excellent books that give information about how people tick which can be fun reads and may be a bit of help. Steven Pinker’s How the Mind Works is a very fun read, for example. There’s not a lot of resources on RPGs and Psychology for a layman’s reading perspective (and honestly relatively little at the scholarly level as well), but I’m hoping to change that in the future. You know, let me think on this and I’ll come back to you… I’m certain I should have a resource or two I could throw your way!

How’s your research coming about, without getting into great detail?
Without getting into great detail? This may not be my area of expertise!
My research is currently mostly in a sort of pilot stage. I’ve been gathering mostly qualitative data at the moment, but I’m working on both measures and a treatment condition. Essentially I want to look at whether social skills (and perhaps other measures of development) can be improved through the use of targeted role-playing games. Where this gets interesting is that role-playing games require fairly significant amounts of theory of mind which is highly correlated with social skills.
P.S. If any psych people are out there and want to steal my research idea… Uh… please don’t? Or if you do, at least get in contact with me and we can collaborate! And if you are going to ABCT, let me know and we should grab a beer!
Progress is slightly slow, but I’ve found several tenured professors who are willing to work with me on this. Mostly I’m trying to figure out some kind of behavioral measure that gives me an idea of what’s happening, because self-report is kind of a flimsy way to do science.

RPGs in some form or other have been used in therapy for years, as far as I understand. Can you recommend any good recent studies or review papers on the topic?
Oh man, you guys just keep on coming up with questions that make me have to think! Once again, I need to make a bit of a separating between ideas.
Roleplaying has been a part of a lot of therapies for quite a long time. It is exceptionally common in Cognitive or Behavioral therapies and pretty frequently used in treatments of certain personality disorders. Additionally, it is used all the time for development of social skills (either in the context of Autism Spectrum Disorders or otherwise!). Most of the time this is something like attempting to understand someone else’s emotional/mental state (understanding the stresses of an alcoholic parent, for example) or practicing skills that are currently at a deficit (practicing making a phone call or initiating conversations).
As for roleplaying games there is slightly less information. In looking for information on RPGs and development, I’ve been spending a ton of time trying to find good articles. Let me tell you, if you want to know about the social structures of MMOs you can swim in papers. I’m still trying to parse a lot of the papers that are actually RPG related, but given that my own focus is on developmental disorders (for RPGs at least, my clinical interest are not really towards this), I’m not the best resource on everything there.
That said, I know off the top of my head one thing I can point you to which is pretty hot off the press!
At the Association for Behavioral and Cognitive Therapies Conference this year, there is going to be a presentation called Using Structured Therapeutic Games to Enhance Empirically Based CBT Treatment for Child Sexual Abuse by Drs. Springer and Misurell. I’m quite excited to be seeing this, because honestly I think that roleplaying games are widely underused in treatment settings! This is based off of a 2012 paper, I believe, but my hope is that it will be something of a push for development of game-based treatments. There are things inherent, I think, in a game over a basic loose roleplay that are additionally beneficial.
I also know that a lot of work is being done currently in decision making for political leaders using roleplaying games, but I’ll admit that I can’t at the moment recall the names of any of the authors or papers related to that! Worst AMA host ever.

I hope these are helpful! Let me know if there are any clarifications, other questions, off-shoot questions, etc that I can answer for you!

[clintmemo]

Yes!

Thanks for sharing that.

[CaptainKobold]

Absolutely! I'd been chomping at the bit to do this since I saw the forum in general. I'm hoping more questions come in and other people also get some AMAs out there!