RUNNING HEAD: PEN AND PAPER 1

Pen and Paper: A Look at Social Anxiety Disorder from the Perspective of Tabletop and Virtual

Role-Playing Games

Andrew Stegenga

Wake Forest University

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Abstract

Social Anxiety Disorder (SAD) affects a broad swath of people in the US regardless of

age, ethnicity, and gender. SAD is marked by anxious feels of negative social evaluation and

performance. There are currently multiple effective treatments that help afflicted individuals

learn to reevaluate social interactions and situations to see them as less threatening. One newly

emerging psychotherapeutic treatment method that has been positively evaluated for treating

symptoms like those persisting in SAD through the implementation of Tabletop Role Playing

games (TRPGs). TRPGs allow for an individual to experience an alternative world and the

influence they can have within it in a safe and low-risk environment. The TRPG experience

ultimately serves as a more enjoyable and lower risk method to learn social skills and

interpersonal navigation as compared to traditional methods, such as CBT, exposure therapy, and

social skills learning programs.

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Pen and Paper: A Look at Social Anxiety Disorder from the Perspective of Tabletop and Virtual

Role-Playing Games

Social Anxiety Disorder (SAD), also known as Social Phobia, currently afflicts 6.3

percent or roughly 15 million Americans according to the Anxiety and Depression Association

of America. The underlying physiological evidence of SAD can be seen through the

implementation of fMRI, Functional Magnetic Resonance Imaging, demonstrating hyperactivity

within the Prefrontal Cortex, Insula, and Amygdala. These parts of the brain have demonstrated

importance in processing self-image and self-consciousness (Stein, 2015). SAD most commonly

surfaces around the age of 13 and afflicts adolescence to a slightly higher degree than other age

groups, however, SAD is still quite persistent among all other age groups. For the purposes of

this Literature Review, I will mainly refer to the affected population between adolescence and

early adulthood, in part because these groups comprise the majority of facilitated research

regarding SAD.

There are effective medications and psychotherapies for dealing with SAD, some of the

most prominent consists of Cognitive Behavioral Therapy that focus on challenging cognitive

distortions and certain modes of thinking, though, another method, used especially for

adolescents, is social skills training (Adaa.org, 2019). Some of the great challenges, especially

with younger clients is to get them excited to attend therapy, therefore it becomes important to

find a method that is both effective in treating SAD and engaging for the client, that’s where

Tabletop and Virtual (MMO) Role Playing Games (TRPG), like Dungeons and Dragons, and

MMORPGs, like World of Warcraft, introduce themselves. Role-playing games have been found

to be effective tools in treating a variety of issues.

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The majority of TRPGs consist of a small group of players, typically anywhere between

two and six, one (usually the therapist or therapeutic assistant in a counseling context) will be

assigned to be the Dungeon Master (DM) or Game Master (GM), although both terms refer to

the same role and are understood interchangeably, for the remainder of the text this special

person will be referred to as the DM.

Each player will create their own unique character with a purposeful backstory,

aspirations, feelings, flaws – these attributes help to uniquely shape how the player characters

will interact in the fantasy world. Although each character creates their own stories as they

interact with each other and the world around them, it is up to the DM as the overarching

narrator of the story to guide the player’s journey to attaining their character goals and ultimately

help to draw parallels between the struggles of the client and the character they play in the game

(Betz, 2011).

MMORPGs, inspired by the classic TRPG format, typically use a similar system for

character creation, often also allowing total customization of hair, eyes, face, and body types to

allow for a more unique player-character bonding experience (Snodgrass, Lacy, Francois-

Dengah, Fagan, & Most 2011). The DM role is largely absent within MMORPGs, instead they

typically use Artificial Intelligence, commonly known in-game as Non-Player Characters

(NPCs), to provide the Player Character (PC) with quests to advance the narrative arc as well as

providing the PC with a “journal” that aggregates information about the quest and storylines as

they progress along their journey (Moser & Fang, 2015).

Methods
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PsycINFO and Google Scholar yielded the most robust results when I was looking for

articles that pertained to using a tabletop or virtual RPGs as a means of therapy for social anxiety

disorder. PubMed, though slightly denser, did provide a fair few articles that reveal useful

information. Articles regarding social anxiety were easy enough to find, though I would also

recommend including “social phobia” as well. In a similar vein, role play takes many forms,

therefore it may prove helpful to perform conjunction searches, such as: “role play OR rpg OR

d&d” as it will funnel more articles that have similar subject matter your way. I also found that

although there was a wealth of information regarding beneficial uses of RPGs, as well as

effective means to treat social anxiety disorders, there was no excess of information that directly

linked the two. If one is to postulate on the effectiveness of RPG therapy in treating SAD from

the current research, it will become apparent that conclusions will be reached primarily on an

inferential basis. It is also important to be aware that research of this subject waxes and wanes,

therefore, I suggest starting your search between 1998 and 2006 as well as between 2011 and

2017 as these dates are particularly information-rich segments of time.

There was one article that was decided to be included despite being outside the

publication range. Dungeons and Dragons: The use of a fantasy game in the psychotherapeutic

treatment of a young adult, authored by Wayne Blackmon and published in 1994, sheds light on

the first inclusion of TRPGs as an avenue that possesses therapeutic qualities.

Results

According to the Diagnostic and Statistical Manual for Mental Disorders Five (DSM-V),

SAD is characterized by 10 diagnostic criteria, of which generally encompasses a persistent fear

of being placed in social situations where an individual could possibly be criticized in any way

and therefore fears that they may act in an embarrassing manner. The DSM also notes that
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individuals may be aware that their feelings are irrational but will still avoid social situations or

present with extreme anxiety for the duration of a social event if it is unavoidable. These

symptoms must be persistent for the individual at minimum of six months and are not caused

medication, substance abuse, or medical issues. An important note in the literature demands that

extra caution is taken went determining Social Anxiety Disorder or Social Phobia, as many of the

symptoms can be confused with Introversion and Shyness (Adaa.org, 2019).

Mainstream Treatments

There is an increasing volume of literature with a psychophysiological approach to SAD

that expands on effective treatments for a variety of age ranges. Such research demonstrates that

Exposure Therapy and CBT are often an excellent method to challenge the distortions that the

client may hold, additionally, there exists mounting evidence for Cognitive Bias Modification

(CBM), that seeks to change cognitive processing of attention and interpretation of threatening

stimuli (Orchard, Apetroaia, Clarke, & Creswell, 2017). Medication used to treat SAD has seen

success in the adult population, however, many concerns exist about its use on adolescents or

young adults that are still developing (Haller, Kadosh, Scerif, & Lau, 2015). Although little

direct research exists linking RPGs as a treatment for SAD specfically, there exist many parallels

between SAD symptomology and the benefits of role play.

TRPGs

At the heart of the role-play experience is healthy dissociation, moving beyond oneself in

an effort to experience life or circumstances as someone equipped with a different set of skills.

One of the first published work that credits TRPGs as providing therapeutic merit was published

in 1994 by Blackmon, who was seeing a schizotypal patient who had noted difficulty conveying
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their feelings during therapy. The client joined a Dungeons and Dragons club at school and

became increasingly attached to the narrative, so much so that it often came up during his

therapy session. Though apprehensive, Blackmon began to inquire about the emotions and

motives that his client’s character experienced. The use of the client’s character as a vehicle for

emotional expression led to a marked difference in emotional openness within therapy. The

client eventually was able to talk about his own emotions without the need to displace them upon

his D&D character.

Daniau’s 2016 study of a group of young adults playing a simplified version of a TRPG

concluded that an experienced player could “learn to play and explore a wide range of specific

learning possibilities,” through these possibilities, she states that it may be possible for the skills

learned for the game to transfer into “human skills.” Depending on the goal of the game, it is

possible for participants to learn “soft skills” such as leadership, diplomacy, and spontaneous

problem-solving that may help to “improve feelings of self-efficacy and perceived competence”

(Daniau, 2016). The hope of using RPGs as a method of intervention with social anxiety is to

teach skills that will transfer from one context to another.

Researchers have examined Dungeons & Dragons or D&D like TRPGs in a variety of

contexts, including the school context in order to learn about their effects on learning and

retention. Cook, Gremo, and Morgan (2017) created a TRPG from Richard Connell’s The Most

Dangerous Game, allowing students to create characters to interact in the setting of the book.

The conclusion of the study resulted that the students were able to make character decisions that

showed a more thorough understanding of the text and were able to successfully collaborate with

one another as they explored the story. The use of an active learning style contributed to the

student’s deeper understanding of the story and the motives behind the actions of the characters
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within. These results are echoed by Wu, Yan, Kao, Wang, and Wu (2016) during their study of

implementing RPGs to enhance learning outcomes. An active learning style has seen great

success in providing students with greater material understanding and promoting a collaborative

classroom environment.

As with most treatments, there is typically a group that is has more interest than another –

D&D is no different. The use of TRPGs specifically, have been noted to draw more interest from

individuals that possess higher tendencies for Perception and Intuition as put forth by the Myers

Brig Type Indicator (MBTI), as indicated by Wilson’s 2007 study. Wilson also reported that

participants remarked that D&D had facilitated “formation and maintenance” of relations.

Although no specific information has been collected along this avenue with MMORPGs as the

focus, it is more than likely safe to assume that there may be significant overlap regarding which

personality characteristics may be more readily drawn to this type of experience.

MMORPGs

Role play is not constricted just to the table-top, there exists a robust community of

players that engage in virtual roleplaying games, MMORPGs. One of the most well-known

MMORPGs to date is that of World of Warcraft (WoW), in 2011 a survey study of 264 WoW

users by Snodgrass, Lacy, Francois-Dengah, Fagan, and Most found support for a relationship

between “dissociation, relaxation, and positive well-being.” The game created a state of

relaxation for some because their level of immersion of the game allowed them to temporarily

forget about real-life stressors, while other participants found WoW to create stress that was

positively stimulating and therefore enjoyable.

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Stress relief is not the only variable studied in the online format, another is that of

socialization. A 2009 study of online WoW players, in part, sought to find evidence that players

attitude toward real-life behaviors would carry over in game. Although there was no definitive

evidence of this research question found from the small population, it was postulated that the

difficulty in finding socially anxious and insecurely attached individual was difficult because the

anonymous nature of online games may be more comfortable and therefore not initiate the same

socially anxious behaviors (Jordan, 2009).

While treatment of SAD could be facilitated through the use of MMORPGs, it has been

noted by Kirby, Jones, and Copello that in some instances of WoW playing, time played has a

negative correlation with psychological wellbeing outside of the game. Psychological wellbeing

was measured by the persistence of “Somatic Problems, Anxiety, Insomnia, Social Functioning,

and Depression.” It was determined that reason for gaming is important for psychological

wellbeing, meaning that if an individual plays as a type of avoidance it correlates negatively,

however, if an individual plays as a method of social interaction it may prove to be beneficial

(Kirby, Jones, Copello, 2014).

Bridging the gap between SAD and Role Play

As it may be inferred, there are many places that RPGs provide benefits and boosts that

align with issues found in SAD clients, though it may seem counter-intuitive to potentially place

clients in the situations that they fear most; it is important to emphasize that it is not the client at

the forefront of the campaign, it is their character, therefore giving them a guise to use to explore

the universe within the RPG. This provides the clients with the ability to act in ways they wish

they could in real life, but without direct, real-life, consequences (Daniau, 2016). Their character

will experience consequences within the world and the client will need to respond to them
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creatively. It was found that participation in Dungeons and Dragons scenarios increased critical

thinking and imagination within the participants (Wilson, 2007). MMORPGs possess similar

benefits and can, therefore, be employed in therapy as well, especially for clients that are more

resistant to the former intervention. In a virtual world, they can still experience a community and

growth from roleplay scenarios while also retaining some anonymity.

A real-world application of D&D is described by George Enfield in the book Using

Superheroes in Counseling and Play Therapy. He describes using TRPGs with four boys; two

who experienced abuse and neglect within their families and two others that experienced

impulsive and aggressive attitudes at home and school. Over the course of a two school semester

TRPG therapy, there was marked reduction of disruption and aggression at home and in the

classroom. An increase in communication between the boys was also witnessed, they were able

to cooperatively plan activities within the game. There were also marked individual

improvements from the condition they experienced before beginning therapy. The boys gained

leadership skills and were more aptly express their own needs and ideas in an effective manner.

Discussion

As hinted in previous sections, there is not a large pool of information with regard to the

implementation of RPG therapy with SAD specifically, however, there are multiple other studies

that have proven such psychotherapeutic means have proven successful in quelling issues that

are parallel with many that emerge from SAD. I would recommend further research into the

direct effects’ RPG psychotherapy on symptoms of SAD. It has been noted that an increase in

effect yield occurs with the inclusion of reflection at the end of the session (Betz, 2011) therefore

the inclusion of post-session reflection is paramount for any further conducted experiment.
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In addition to tabletop RPGs, there is evidence in the effectiveness of Live Action Role

Play (LARP) in treating elements parallel with SAD, however, little research has been conducted

between SAD and LARP directly. This route of Live Action Role Play could potentially yield

interesting results for those suffering from SAD that wish to be more physically active in

therapy. The inclusion of physical activity itself could potentially bring in an entirely new set of

variables.

Another potential field for further investigation of the persistence of social anxiety is

through the use of video game worlds. There seems to be an emerging following of knowledge

postulating the benefits of Massively Multi-user Online Roleplaying Games (MMORPGs), such

as World of Warcraft, however, there is relatively little research on the social environment of

other genres of games. With the advancement of technology, comes the introduction of Virtual

Reality (VR), which most notably exponentially increases game immersion through the use of a

headset and eye covering that places any gamer right in the middle of their world of choice, in

which they can interact with the environment more directly than with a standard controller, this

is because they are physically able to perform the actions (i.e. unsheathing a sword, picking

apples, opening doors). VR communities have yet to be much of a subject with regard to

potential alleviation or exacerbation of Social Anxiety Disorder.

The relative stability in the persistence of SAD across all age groups, at least as shown in

the US, should mark the need for more in-depth and diverse study of effective general treatments

that can work across all age groups, as current literature seems to be limited to adolescences

through young adulthood. Since there are differing socio-cultural conclusions regarding the

method and importance of social interaction, it may be interesting to conduct further research on

the prominence of SAD and TRPG therapy across varying cultures, as much research originates
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in the US, while very few linking studies have been conducted in exceptionally different

cultures.
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References

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