Running Head: USING DUNGEONS AND DRAGONS AS THERAPY 1

The Anxious Warrior:

Using Dungeons and Dragons as Therapy

Andrew Stegenga

Wake Forest University

USING DUNGEONS AND DRAGONS AS THERAPY 2

Table of Contents

Rational 3

Group Objectives 6

Informed Consent 7

Detail Groups Sessions 9

Outcome Evaluations Questionnaire 18

Resources 19

Application Issues 21

References 23
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Rational
Anxiety persists in 40 million Americans or 18% of the US population. Of persisting

anxiety, Social Anxiety or Social Phobia affects 15 million individuals (ADAA, 2019). Social

Anxiety Disorder or SAD is marked by intense fear of ridicule for poor social evaluation by

peers (American Psychiatric Association, 2013). Although SAD presents in most age groups,

ages 15-16 and 17-18 possess the highest prevalence rates (9.7% and 10.1% respective), with

many individuals being affected since age 13, additionally 36% of individuals with SAD report

experiencing symptoms for 10 or more years before seeking treatment (NIMH, 2019). Social

Anxiety is often treated through CBT or skill training, though an emerging group therapy has

shown some initial promise. Dungeons and Dragons (D&D) is a tabletop role playing game

(TRPG), where players engage with one another as fictional characters and engage in adventures

within a fantasy land. The use of an alternate character in a fictional universe would allow an

individual with persistent anxiety to explore actions and consequences with lower risk. Utilizing

the fictional character, the individual will be able to explore how that character handles

emotions, interactions, and critical decision making with regards to social situations and will

come to integrate the lessons learned by their fictional character with their actual self.

A counseling group type has been chosen as the appropriate form because of the

emphasis on improvement of relationships between each member and those they will meet as

well as the improving personal growth of each individual (Gladding, 2015). The size of the

group would consist of 3 or 4 individuals, this is a typical size of both a counseling group for

kids and the recommended number of players for any given therapeutic Dungeons and Dragons

adventure (Enfield, 2007). Keeping the group small will allow more time for each member to

create and attune bonds between party members. Additionally, this group size will allow the
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group leader to focus more intensely on the goals of each group member (Daniau, 2016).

Typically, counseling groups last for 6 to16 sessions (Gladding, 2015), though with the long

format of D&D, it may be more realistic for somewhere between 12-24 sessions. Additionally,

while a one-hour session would be possible, content would be condensed, therefore, two-hour

sessions would be more appropriate for this format. Two hours is also the minimum time that

Daniau suggests, as longer play sessions allow for greater consolidations of group imagination

(2016). Little is required for this type of group therapy, though a room with a table and chairs

would suffice. Lighting should be dimly lit to convey a relaxed feeling and should provoke more

self-disclosure. Distance between each member would be semi intimate, though the members

may be somewhat comforted by the table as defensive layouts are favored by clients (Gladding,

2017).

The proposed theoretical framework would incorporate a combination of Gestalt and

Cognitive Behavioral therapies. Gestalt therapy is of interest due to its heavy emphasis of the

‘here and now’ sensations and its utilization of experience for self-discovery (Gladding, 2017).

Gestalt makes use of many exercises, such as roleplay and psychodrama, which is the basis of

Dungeons and Dragons. Emphasis on the doing rather than just talking allows for a

multidimensional approach to self-discovery as each member will be able to examine not only

their words for change, but also their interactions with characters in the fantasy environment

(Coe, 2017). It is often difficult to provide a strong sense of character agency if too much

situational and narrative control is exerted by the Dungeon Master (DM), or group leader in this

case. While it may be necessary to steer characters to certain objectives, the interactions of the

characters with the fantasy environment can take on a very tentative nature and any preparation

may take a back seat. This nature also coincides with the Gestalt idea of viewing therapy as “a
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series of experiments” (Gladding, 2017). Daniau’s research suggests that role play is most

effective when coupled with reflection of the adventure of the session. This is referred to in

much of the same way as CBT, with its emphasis on combating cognitive distortions.

Anecdotally, there has been successful implementation of tabletop RPGs into therapy by

George Enfield and Wayne Blackmon. In Enfield’s collaborative book Becoming the hero: The

use of role-playing games in psychotherapy, he reports success with male clients that come from

difficult backgrounds. Of the successes was a boy who came to therapy that had no regard for his

own emotions or wants and always conceded to the whims of others. Improvement in his ability

to state his own wishes were seen after only a few group sessions. Blackmon also offered an

account of success with a schizotypal patient that enjoyed talking about the Dungeons and

Dragons game that he played after school. Blackmon inquired about the motivations and

emotions of the character his client played and used the character as a vehicle to encourage

emotional expression of his client. Eventually his client was able to express his own emotions

without the need of displacing them upon his D&D character.

This treatment is largely still emerging, with little empirical research, though there has

been some progress made with examining how the dynamic of the group and individual

motivation affects outcomes. As hinted at earlier, Daniau’s research suggests that one third of the

time spent in the session should be devoted to reflections of the adventure and connecting

feelings, thoughts, and actions between each character and the member that portrays them

(2016). This reflection is critical to facilitate soft skills such as leadership, diplomacy, and

spontaneous problem solving; despite playing a role outside of oneself, players still develop

skills that can transfer to real life. Individuals encounter transferable soft skills through fictive

battles, puzzles and interactions with the fantasy land as the characters collaborate, gather
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information, drawn on previous experiences, make spontaneous decisions, and experience

consequences of their actions. According to Coe, another motivating feature to play TRPGs lies

in the ability to explore oneself more thoroughly. This is seen in the ability to create characters

that represent oneself or explore aspects of themselves that they wish to know better or to better

flesh out (Coe, 2017).

While the field is still in its infancy, there has been a glimmer of hope that Social Anxiety

Disorder as well as other DSM diagnoses may be treated through the use of tabletop role playing

games like Dungeons and Dragons, as they offer an alternative to traditional treatment and have

the potential for great skill transference and self-discovery.

Group Objectives

Through adventuring together in a narrative fantasy land, the following objectives are hoped

to translate from fantasy to reality.

 To reduce and individual’s negative affect caused by personal mishaps in public and

during social interactions.

 To implement a narrative framework to foster an environment that allows for

explorations of cause and effect reactions related to character decisions, without fear of

undue ridicule, reprimand, or alienation from peers. This includes encouraging the

expression of one’s own voice that allows them to share their personal needs and desires

with those around them.

 To promote and model healthy social support relationships between individuals and

others through group cohesion formed by cooperation and role exploration.

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Informed Consent

The group you are considering being a part of utilizes Dungeons and Dragons inspired

role play to treat adolescents with social anxiety over the course of 16 weeks. During the group

meetings, you will create a character and be faced with numerous fantastical adventures. Each

session will last two hours that will be spent on reflection, gaming, and integration.

Confidentiality

Your therapy is distinctly catered to you and the other individuals within the group;

therefore, session meetings will remain confidential between your facilitator and the members of

the group. Because narrative stories are being created and members may want to recount heroic

feats or narrow escapes to individuals outside of the group, it will be urged to only recount the

events that occur by using the names of the characters within the game and refrain from using

names of other members of the group during any retelling. To ensure confidentiality to the best

of the facilitator’s ability, during the first session this confidentiality clause will be reiterated in

addition to periodically as the sessions progress.

While confidentiality is an important measure to maintain counselor-client trust, it must

be noted that confidentiality can be broken if the following instance ensue: 1) Credible threats of

suicide or harm against oneself or another, 2) evidence of abuse against a child or elder, and 3) if

records are subpoenaed by a court. Outside of the previously mentioned circumstances,

information can only be shared with your expressed consent.

Risks of Group Therapy

There are inherent risks when sharing therapy with other individuals. While engaging in

storytelling, you may come across sensitive emotions that feel uncomfortable or difficult to
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express. While this is normal, you should always communicate with the facilitator about how

you are feeling if you are uncomfortable discussing it with the group. While confidentiality is

strongly urged and will be recited, there is always a small chance that information shared in the

group may expand outside of the group either intentionally or unintentionally, this will be

addressed appropriately on a case by case basis.

Your signature below will serve as written consent to enter the group as well as indicates

that you have read and understood the information outlined above.

Name ______________________________________________________________

Signature _____________________________________________ Date _________

Parent/Guardian Name_________________________________________________

Parent/Guardian Signature________________________________ Date _________

Facilitator signature _____________________________________ Date _________

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Detailed Group Sessions

Session 1: Character Creation

The first session is to help the members get acquainted with the format of Dungeons and

Dragons as well as obtaining the necessary narrative components to allow them to interact in the

fantasy world.

Materials: Informed Consent, D&D Rule Book, Gaming Etiquette sheet, Class flowchart,

character sheets, backstory sheet, writing utensils, five (5) sets of polyhedral dice

Introductions (10 minutes):

The facilitator will introduce themselves and state their favorite letter and write it on a

portable dry erase board. Each group member will take turns introducing themselves and stating

their favorite letter (or any letter from the alphabet) and copying it to the dry erase board; once

each member has introduced themselves, then the written letters will be spoken aloud and group

will be informed they helped to create the name of the character that will aid the members of the

adventuring party and will be played by the facilitator. The facilitator will proceed to the

character creation activity.

Character creation activity (45 minutes)

The facilitator will hand out character flowchart, character sheet, and character backstory

sheets. Gaming etiquette expectations will also be discussed. Sets of polyhedral dice and writing

utensil should also be distributed. Using the distributed materials, the facilitator and group

members will begin to create their character following instructions from the rule book that is

read aloud by the facilitator. To start everyone will select a specialization or class they are
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interested in from the flow chart, then they will be direct to roll the dice to determine what their

characters are good and bad at. After determining skills, players will begin to write a brief

backstory on the provided corresponding sheet. This can be expanded at any time and serves

mostly as a launching point. After character creation is complete the facilitator will move to the

warm-up activity.

Warm-up activity: Creative Imagery (15 minutes)

The facilitator will guide each member to imagine neutral or pleasing people, places, or

things, making sure to shift between different images multiple times. Members will then be

asked to describe or suggest images for the facilitator to describe. After each member has

suggested an image, the facilitator will begin to describe one last fantastical setting.

Brief game session (35 minutes)

The last scene described by the facilitator will serve to set the scene where the

adventurers will meet – a hillside festival outside of a coastal town. The facilitator’s character

will select this group to help him gather the wagon with a special artifact inside. During this

process, the characters can introduce themselves. Inevitably, the party returns with the wagon to

find other festivalgoers encased in a heavy layer of ice. The distant town seem to be undergoing

a blizzard, the water also seems to be frozen over. Session end.

Awareness activity/Conclusion (15 minutes)

After the game session, the facilitator should give each member time to reflect on the

following questions:

In what ways does your character reflect yourself?

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What ways will they differ?

How do you hope to relate to your party members?

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Picking your class

https://thedungeonhacker.com/2017/01/15/dnd_class_flow_chart/
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Character Backstory

Questions to consider: Draw yourself!

Do you have any siblings?
Are you from a large city or a small village?
What is the name of your home?
What is your village known for?
Why did you leave?
Describe a special item your character has.

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Character Sheet
USING DUNGEONS AND DRAGONS AS THERAPY 15

https://media.wizards.com/2015/downloads/dnd/DDALRoD_CharacterSheet.pdf
Gaming Etiquette

https://i.pinimg.com/originals/be/1f/13/be1f134fd104b4ac828a7e7b5139117c.jpg
USING DUNGEONS AND DRAGONS AS THERAPY 16

Session 10: The Adventure

As with most sessions outside of the first, the core of the session is to draw elements from

gameplay to apply them to the player as well as incorporating therapeutic techniques into

gameplay to raise awareness on the narrative (character) and meta (personal) levels.

Materials: D&D Rule book, character sheets, backstory sheet, writing utensils, five (5) sets of

polyhedral dice

Opening activity: Making the Rounds (15 minutes)

The meeting should open with a recap of the previous sessions leading up to current

events. The warmup activity will be initiated from within the game; as the adventuring party

returns the stolen ice crown relic to the pulpit in the crypt, they are all overcome with the

courage to speak deep truth. Group members will take turns revealing something their character

has been closely guarding. Players are encouraged to reveal a secret that is confrontational in

nature, so that character can work through unfinished business. Once issues are revealed and

settled the game resumes.

Game session (60 minutes)

After the warmup task, players are asked to explore the different feelings their characters

are experiencing. The crown’s return to the pulpit activates a ray of light guiding them to a

hidden door that has been revealed on the other side of the ice crypt. Players will investigate and

be confronted by ice warriors. Continuing to the passage, players be met with numerous

distressing scenes played out by shifting ice. Continuing to a large throne room, they encounter

various enemy ice monsters commanded by a large ice golem that seems to hold someone within
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it. After successfully defeating the ice golem’s army, the golem will melt to reveal the

facilitator’s character that had gotten lost the session prior. The fate of this character is up to the

facilitator’s discretion. The ray of light still directing them beyond an ice wall, the players must

now solve a puzzle to proceed. The wall begins to melt and the session ends.

Exaggeration of physical responses to scenes and scenarios is important to draw attention

to, therefore the facilitator should direct players to inspect their actions and exaggerate them. To

maximize effectiveness, the facilitator should use emotional descriptors to elicit unique

emotions, especially disgust, as it will prove useful in personal reflection by the players, as

illustrated by Oum (2010).

Awareness activity: Role Reversal (20 minutes)

Players will be encouraged to pick an interaction from the past session and asked to

switch roles with another player so they can examine the scene from an alternative perspective,

trying to examine which emotion the assumed character may have felt and which of those

emotions may parallel those felt by their actual character. One example may be swapping places

with the facilitator’s character in the ice and getting to watch the fierce battle play out while

being unable to help friends in need.

Concluding activity (25 minutes)

Each member should describe which moment of the session was most impactful for both

their character and for themselves as the player. After each member has shared, the facilitator

will assign group homework:

What advice would your character give to you? For the next session, bring in one

example that illustrates how you followed your character’s advice.

USING DUNGEONS AND DRAGONS AS THERAPY 18

Outcome Evaluation Questionnaire

We appreciate your honest feedback on the program.

1) How was your overall experience?

2) Which aspect of the adventure provided the most self-reflection?

3) What aspects of the facilitator’s narrative style added most to the experience?

4) Which aspects of the facilitator’s style detracted from the narrative experience?

5) Which awareness activity benefited you the most?

6) Did any aspects of the adventure detract from your growth?

7) What would you add to the adventure to improve it?

8) Did your time in fantasy allow you to explore realistic interpersonal interactions?
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Resources

For members and their families:

 An overview of Social Anxiety Disorder: https://www.webmd.com/anxiety-

panic/guide/mental-health-social-anxiety-disorder#1

 For those that are unaware of Role-Playing games and want to know what it is.

http://wheelhouseworkshop.com/2016/04/27/what-exactly-is-a-tabletop-role-playing-

game-anyway/

 Podcast Interview with leading clinicians that incorporate Dungeons and Dragons in

therapy: https://www.youtube.com/watch?v=OTynipvVz8M

 A link to a Blogger’s personal advice about dealing with social anxiety. “5 Seconds of

Courage” will be especially helpful at the table: https://nerdsonearth.com/2014/10/nerds-

advice-overcoming-social-anxiety-5-seconds-courage/

 National contact for more information on the intersection between therapy and role play:

https://gametogrow.org/contact/

For Group Leaders:

 Official D&D ‘Rules:’

https://media.wizards.com/2015/downloads/dnd/DMBasicRules.pdf

 A description of different types of players and styles of fun:

https://www.youtube.com/watch?

v=LQsJSqn71Fw&feature=share&fbclid=IwAR1cTqnSZYexLwIbkJW51vN6NPAQ-

o6ZJvmi7adjf8C8Y26g7Zf6EYlo1eM
USING DUNGEONS AND DRAGONS AS THERAPY 20

 How to help players step into their characters through narrative:

https://www.youtube.com/watch?v=IC4KFnv4jIU&feature=youtu.be

 To help facilitators get a glimpse into the perspective of the socially anxious, the

following link describes a game where players help an anxious girl make oatmeal – game

download links included:

https://www.gamasutra.com/view/news/271251/Every_decision_is_wrong_Portraying_so

cial_anxiety_in_a_game.php

 A book to reframe how social values may influence facilitator’s expectations of the “end

goal”: https://www.amazon.com/Quiet-Power-Introverts-World-

Talking/dp/0307352153/ref=sr_1_1?ie=UTF8&qid=1414250338&sr=8-

1&keywords=quiet&pldnSite=1
USING DUNGEONS AND DRAGONS AS THERAPY 21

Application Issues

The proposed group plan is more involved than some tabletop roleplaying games, though

the demand for a room with chairs, a table, and a few printable supplies should not cause

significant problems. If the session cannot be held within a specific room, it can easily be shifted

to a different, but equally accommodating environment. While the hope to provide a special item

to officiate the transformation from player to character, such as a tiara, is valiant, there are some

practical issues with keeping up with small items.

Social anxiety has a component of performance anxiety related to it and roleplay is

inheritably a type of performance. If the facilitator does not link each individual effectively then

they run the risk that some members may be unwilling to engage in the adventure because they

are afraid of being negatively evaluated. Also depending on the nature of each group member

and the collaborative decision-making process combined with the gestalt therapeutic lens, a

difficulty may arise if an impasse is reached and characters are unable to reach a mutually

agreed-upon decision (Gladding, 2015). There may be some concerns that by allowing violence,

even fantasy, it may inadvertently provide encouragement for group members to utilize violence

as a problem-solving technique.

There exist some ethical concerns regarding the appropriateness of implementation. Such

is that roleplay is not recommended for individuals who possess a weak grip on reality as it may

only facilitate further blurring between the fantasy world and reality (Adams, 2013). With this in

mind, it is necessary to conduct appropriate evaluation when considering the client’s fit for this

program. Further research conducted by Lee and Leeson (2015) also suggests that escapist

behavior similar to that of addicts may emerge in a small percentage of extremely maladapted

individuals, as they either cannot cope or refuse to invest in reality, opting instead for a fantasy
USING DUNGEONS AND DRAGONS AS THERAPY 22

where their presenting issues do not exist. It should also be noted that this is more commonly

found in videogames centered around roleplaying. While Gladding (2015) mention that roleplay

is suitable for all ages, there still is not a wide array of information regarding efficacy of role

play with different ethnic or cultural groups, aside from limited preliminary research that Gestalt

playgroups, similar to roleplay, is effective with cultures that value academic achievement, such

as Chinese and Taiwanese (Gladding, 2015).

USING DUNGEONS AND DRAGONS AS THERAPY 23

References

Adams, Aubrie S. (2013) "Needs Met Through Role-Playing Games: A Fantasy Theme Analysis

of Dungeons & Dragons," Kaleidoscope: A Graduate Journal of Qualitative

Communication Research: Vol. 12, Article 6.

American Psychiatric Association. (2013).  Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author.

Anxiety and Depression Association of America, ADAA. (2019). Retrieved 17 September 2019,

from https://adaa.org/about-adaa/press-room/facts-statistics

Blackmon, W. D. (1994). Dungeons and Dragons: The use of a fantasy game in the

psychotherapeutic treatment of a young adult. American Journal of Psychotherapy, 48(4),

124–132.

Coe, D. F. (2017). Why People Play Table-Top Role-Playing Games: A Grounded Theory of

Becoming as Motivation. The Qualitative Report, 22(11), 2844-2863. Retrieved from

Daniau, S. (2016). The transformative potential of role-playing games: From play skills to

human skills. Simulation & Gaming, 47(4), 423–444.

Enfield, G. (2007). Becoming the hero: The use of role-playing games in psychotherapy. In L. C.

Rubin (Ed.), Using superheroes in counseling and play therapy (pp. 227-241). New

York, NY, US: Springer Publishing Co.

Gladding, S. T. (2015). Groups: A Counseling Specialty. New York: Pearson Education.

USING DUNGEONS AND DRAGONS AS THERAPY 24

Gladding, S. T. (2017). Counseling: A Comprehensive Profession. New York: Pearson

Education.

Lee, B. W., & Leeson, P. R. C. (2015). Online gaming in the context of social anxiety.

Psychology of Addictive Behaviors, 29(2), 473–482.

NIMH Social Anxiety Disorder. (2019). Retrieved 18 September 2019, from

https://www.nimh.nih.gov/health/statistics/social-anxiety-disorder.shtml

Oum, Robert, "Psychophysiological Responses to Disgust: Cardiovascular and Facial Muscle

Patterns Associated with Different Functional Domains" (2010). Open Access

Dissertations. 502.