Review

Simulation & Gaming

2022, Vol. 0(0) 1–27
Therapeutic Use of © The Author(s) 2022
Article reuse guidelines:
Role-Playing Game (RPG) in sagepub.com/journals-permissions
DOI: 10.1177/10468781211073720
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Mental Health: A Scoping
Review

Daniel Luccas Arenas1,2 , Anna Viduani1, and

Renata Brasil Araujo2

Abstract
Background. Role-playing game (RPG) is a term that covers a series of forms and
styles of games that involve, in some way, the creation, representation and
progression of characters who interact in a fictional world under a system of
structured rules. Its applications and effects on human behavior and mental
health are, however, still an underexplored area.
Methods. A scoping review was performed on the literature about RPGs as a
therapeutic tool or prevention strategy in psychotherapies and mental health,
highlighting studies’ populations, forms of RPG and interventions used. To that, a
systematic search in the PubMed/MEDLINE, Embase, PsycINFO, BVS/LILACS
databases and grey literature was performed.
Results. Of the 4,069 studies reviewed, 50 sources of evidence were included. The
majority was published as of 2011 (78%) in journals (62%) and targeted ther-
apeutic uses of RPGs (84%). Most interventions used computer (50%) or ta-
bletop RPGs (44%), mostly with cognitive and/or behavioral (52%) therapeutical
approaches and targeting adolescents (70%).

1
Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
2
Department of Education and Research, Hospital Psiquiátrico São Pedro, Porto Alegre, Brazil

Corresponding Author:
Daniel Luccas Arenas, Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Rua Ramiro
Barcelos, Department of Education and Research, Hospital Psiquiátrico São Pedro, Porto Alegre-90040-
060, Brazil.
Email: dan.arenas@gmail.com
2 Simulation & Gaming 0(0)

Conclusion. The findings suggest a potential use of RPGs as a complementary tool in

psychotherapies. However, only 16% of the studies included were experimental.
We identified considerable heterogeneity in RPGs definitions, outcomes and
interventions used, preventing a systematic review. Thus, more empirical and
well-designed studies on the application of RPGs in mental health are needed.

Keywords
role-playing games, games, mental health, psychotherapy, prevention, scoping review

Introduction
The term role-playing game (RPG) covers a series of forms and styles of ludic activities
practiced by different social groups (Zagal and Deterding, 2018). Its origins come from
1974, with the launch of Dungeons & Dragons (D&D). D&D combined elements of
wargames, fantastic literature, and role-playing (Gygax and Arneson, 1974). Since
there, other forms of RPG have emerged, spreading through different media, influ-
encing and being influenced by diverse cultural contexts (Deterding and Zagal, 2018).
Due to its socio-material heterogeneity and its transformations over time, there is no
consensus on a universal definition for the term RPG that is sufficiently comprehensive,
although some elements are usually common: (a) at least one player who plays and
controls at least one character; (b) at least one game master or narrator, either a human
figure (an in-person game master that verbally conduces the narrative and controls the
game world, non-playable characters, and distributes rewards/enhancements to the
characters) or a digital system (digital elements and narratives that are automated
through programming and conduces the characters in the game world according to the
actions of the players); (c) a fictional scenario or universe where the game takes place;
(d) a system of rules that can be flexible or rigid; (e) a narrative which can be linear or
co-constructed; and (f) the interaction between all these elements (Zagal and Deterding,
2018). Nonetheless, we can divide these elements according to some characteristics, such
as their main forms: tabletop RPG (TRPG); live-action RPG (LARP); computer RPG
(CRPG); multiplayer online RPG (MORPG) or massively MORPG (MMORPG) and
others hybrid forms (Hitchens and Drachen, 2009; Zagal and Deterding, 2018) (Table 1).
With the popularization of RPGs and their growing cultural and behavioral in-
fluence, researchers have investigated their possible applications in various areas of
knowledge, highlighting their potential positive and negative effects (Deterding and
Zagal, 2018; Fine, 1981, 1983; Scott and Porter-Armstrong, 2013). Some studies have
shown an association between the practice of RPG with greater motivation and self-
efficacy (Bowman, 2014; White, 2008), creativity (Daniau, 2016; Dyson et al., 2016;
Meriläinen, 2012), empathy (Rivers et al., 2016), well-being (Scott and Porter-
Armstrong, 2013) and increased social connections, engagement and a sense of be-
longing (Adams, 2013; Daniau, 2016; Fein, 2015; Sargent, 2014). Thus, the literature
Arenas et al. 3

Table 1. Characteristics of RPG forms (Zagal and Deterding, 2018).

TRPG LARP CRPG MORPG/MMORPG

Player One or more players One or more players A single player with Several players access the
gathered gathered access to a computer game synchronously or
synchronously synchronously in a asynchronously through
around a table or pre-established space computers connected
online via the Internet
Character Players create, interpret Players create, interpret The player creates, The player creates,
and control the and control the customizes, and/or customizes, and assumes
actions of their actions of their assumes the role of the role of a character
characters verbally. characters verbally one or more through the actions
Characters evolve and physically. It is characters through the available in the interface
through a progression common to actions available in the and mechanics of the
system characterize and use interface and game. Characters evolve
physical props mechanics of the game. through a progression
Characters evolve system
through a progression
system
Storyteller/ A game master One or more game Role assumed by the Role assumed by the
Game determines the masters organize the computer, which server, which executes a
master scenario, guides the scenario, guide the executes a programmed model of
narrative, interprets narrative, and manage programmed model of the rules and the game
the non-playable the rules and the the rules and the game world in view of the
characters, and players. They can world in view of the interaction with the
manages the rule count on auxiliary interaction with the players. It includes all
system and actions of participants who are player. It includes all non-playable characters,
the players instructed to play non-playable the plot, the interface,
certain roles of non- characters, the plot, and the audiovisual
playable characters the interface, and the representations. It is
audiovisual updated frequently
representations
Scenario/ A fictional world built A fictional world that A fictional world formed A fictional world formed
Game through verbal uses the real world as by audiovisual by audiovisual
world communication, a play space. The representations representations
imagination and characters are generated by a generated by a
interaction between incorporated by the computational model computational model
the game master and participants and real that supports the that supports the
the players. It can rely or scenographic player’s imagination players’ imagination
on support tools such objects are used to
as thumbnails, maps, provide a greater
tokens and rules degree of realism or
verisimilitude
Rule system It provides structure and It provides structure and It bases the mechanics of It bases the mechanics of
generally has a guarantees safety and the game. Usually, the the game. Usually, the
quantitative and respect during the character’s skills and characters’ skills and the
probabilistic game. It provides the results of their results of their actions
character. It provides bases and acts as a actions are determined are determined by a
foundations and acts guide for combats, by a system of system of quantitative
as a guide for actions, creation and quantitative and and probabilistic rules or
combats, actions, evolution of probabilistic rules or the players’ skills. It can
creation and characters, the player’s skills provide greater security
evolution of delimitation of space, and respect during the
characters, and game and game dynamics game
dynamics

(continued)
4 Simulation & Gaming 0(0)

Table 1. (continued)
TRPG LARP CRPG MORPG/MMORPG

Narrative Dynamic and co- Dynamic and co- Usually, guided by a pre- Usually, guided by a pre-
constructed through constructed through established plot with established storyline
communication and communication and beginning and end and with beginning and end
interaction between interaction between executed by a and executed by the
players and game players, game master, computer program. It computer program.
master. It can be and the physical may allow you to play Players influence it. The
guided by a pre- environment. It can be openly before, during, narrative is always
established storyline guided by a pre- or after the narrative updated. Allows you to
and take place in one established storyline content completion. It play openly before,
or more game and take place in one usually requires more during, or after the
sessions or more game than one game session completion of the
sessions narrative content. It
requires more than one
game session
Interaction It occurs through verbal It occurs through verbal It occurs through the It occurs through the
communication and non-verbal player’s available communication
between the players communication actions in the game between players and the
and the narrator in a between players, interface mediated by a player’s available actions
synchronous way. It is narrators, and the computer and limited in the game interface
mediated and limited environment in a by the rules mediated by a computer
by the imagination synchronous way. It is and limited by the rules.
and guided by a mediated and limited Players can collaborate,
system of rules, with by the rules, compete, or ignore each
auxiliary instruments imagination, other during the shared
such as tokens, data, participants’ physical experience
miniatures, and maps abilities, and the real
world’s physical and
social laws
Examples D&D (Gygax and Underworld Ultima (Garriott, 1981), EVE Online (CCP Games,
Arneson, 1974), Call (underworldlarp. Diablo (Blizzard 2003), World of
of Cthulhu (Petersen, com), Oxford Entertainment, 1996), Warcraft (Blizzard
1981), World of Renaissance Festival Final Fantasy VII Entertainment, 2004),
Darkness (renfest.ca), College (Square, 1997). Old School RuneScape
(Rein-Hagen, 1991) of Wizardry (Jagex, 2013).
(witchards.com)

CRPG, computer role-playing game; LARP, live-action role-playing game; MORPG, multiplayer online role-
playing game; MMORPG, massively multiplayer online role-playing game; TRPG, tabletop role-playing game.

highlights its potential benefits in educational (Bowman, 2014; Jabbar and Felicia,
2015) and psychological (Bowman and Liberoth, 2018; Lieberoth and Trier-Knudsen,
2016) contexts. Examples include the development of social, communication, and
problem-solving skills (Adams, 2013; Bowman, 2008, 2010; Daniau, 2016; Sourmelis
et al., 2017) and even the therapeutic use of RPG (Bowman and Liberoth, 2018;
Lieberoth and Trier-Knudsen, 2016). The latter is usually delivered through gamified
strategies (use of game elements for a specific purpose other than entertainment)
combining RPG elements, or by the development of serious games (developed for a
specific purpose beyond entertainment) based on RPGs (Fleming et al., 2017). The use
of games in mental health has gained a lot of academic attention, with reviews focusing
on the development of games for mental health and the treatment of mental disorders
(see Shah et al., 2018; Turner et al., 2016).
Arenas et al. 5

Despite the growing interest in the effects of RPG on human behavior and its
therapeutic potential, the topic is still understudied and under-documented, with no
systematic reviews available. Therefore, there is a need for reviews capable of mapping
the available literature broadly and systematically, identifying gaps and perspectives for
research, which is congruent with scoping review methodologies (Peters et al., 2020;
Pham et al., 2014).

Methods
The objective of this work is to understand how RPGs have been used as a therapeutic
tool or as a prevention strategy in mental health. In this sense, secondary outputs
included mapping the profile of the population in which RPG-based interventions were
used, the RPGs forms used, the types of interventions that have been studied, and the
outcomes evaluated in the literature.
A multidisciplinary research team conducted a scoping review based on Arksey and
O’Malley’s framework (Arksey and O’Malley, 2005), adapted by Levac and colleagues
(Levac et al., 2010). The scoping review protocol was registered with the Open Science
Framework on August 17, 2020 (osf.io/w827x). The question that guided the review
was: “What evidence is available on therapeutic or preventive applications of RPG in
mental health contexts and what are its characteristics?”.

Inclusion/exclusion criteria
The review included studies that included: (a) population: patients and/or players of any
age group; (b) concept: used RPG as a strategy for prevention and/or as a therapeutic
tool; (c) context: in the context of psychotherapy or mental health; (d) were published
between 1974 and 2020, and (e) were written in Portuguese, English or Spanish.
Otherwise, studies focusing on the use of RPG in strictly educational contexts were
excluded.
RPGs were defined as a series of forms and styles of playful activities practiced by
different social groups, individually or in groups, and that involves, in some way, the
creation, representation, and progression of characters (i.e., characters evolve and
improve certain aspects and skills throughout the game) who interact in a fictional
world under a structured rules system (Zagal and Deterding, 2018).

Search strategy
The research team defined the database and search strategies employed, with the advice
of two independent librarians with experience in health sciences (for complete search
strategy, see Supplemental Material 1). The search included theoretical and empirical
studies from published or unpublished data sources (Arksey and O’Malley, 2005;
Levac et al., 2010). Also, the databases used for the search were: PubMed/MEDLINE,
Embase, PsycINFO, and BVS/LILACS. To search for unpublished studies, we used:
6 Simulation & Gaming 0(0)

OpenGrey, GreyNet, Google Scholar, BASE, and Plataforma Sucupira. The last search
in the databases was on 01/23/2021. Furthermore, a snowball technique was used to
review citations present in relevant evidence sources.

Study selection
Two independent reviewers (DA and AV) performed the search and selection of evidence,
according to the inclusion criteria. In the first stage, duplicates were excluded, and titles
and abstracts were screened. In the second stage, full text of all articles included by at least
one reviewer was analyzed according to the eligibility criteria. The research team
contacted authors by email or social media in cases where the full report was not available.
One pilot test was conducted to measure and calibrate the inter-evaluator agreement
with 15% of the sample of the first stage (Arksey and O’Malley, 2005). In this phase,
the principal researcher (DA) calculated the kappa index, followed by a discussion of
the criteria among the members of the research team and kappa recalculation at the end
of the first and second stages of evidence selection. Kappa greater than 0.8 was
considered representative of good agreement between the evaluators (Landis and Koch,
1977). A third reviewer (RA) decided on cases of divergence by discussing each case
and reaching a consensus. We used the Zotero software (Rosenzweig, 2016) for citation
management and duplicate exclusion, and the Rayyan web-application (Ouzzani et al.,
2016) for selection of titles and abstracts.

Data extraction
Two independent reviewers performed data extraction (DA and AV) with supervision by
a third reviewer (RA). With 10% of the sample reviewed, a discussion was held between
the reviewers to calibrate data extraction. Disagreements were resolved by consensus.
Reviewers formulated a table containing the main characteristics of the selected studies,
which included the title, first author, year of publication, type of publication, country of
origin, objectives, study design, the sample with inclusion/exclusion criteria, RPG form,
characteristics of interventions, outcomes, and measures, and, lastly, the main results.

Synthesis and presentation of results

Extracted data were compiled, and a descriptive quantitative analysis was performed by
calculating the frequency of characteristics relevant to the review question. Qualitative
descriptive content analysis was also carried out. Data was coded and categorized using
the NVivo software (Richards and Richards, 2020).
The validated Mixed Methods Appraisal Tool (MMAT) version 2018 (Hong et al.,
2019; Pluye et al., 2009) was used to perform a critical appraisal of the primary
empirical sources of evidence. The quality of the studies was scored using a nominal
scale and divided into: (1) qualitative studies; (2) randomized controlled trials (RCT);
Arenas et al. 7

Figure 1. Flow chart of scoping review process.

(3) non-randomized studies; (4) quantitative descriptive studies; and (5) mixed-
methods studies (Hong et al., 2019).
Included studies were presented through a descriptive summary, using tables and
narrative synthesis. In this article, we followed the PRISMA extension for reporting
scoping reviews (PRISMA-ScR) (Tricco et al., 2018) (Supplemental Material 2).
8 Simulation & Gaming 0(0)

Table 2. Characteristics of the publications included.

Characteristics Categories n=50 %

Publication period 1974-1990 3 6

1991-2000 5 10
2001-2010 3 6
2011-2020 39 78
Language of publication English 44 88
Portuguese 5 10
Spanish 1 2
Study location United States 20 40
Brazil 7 14
New Zealand 5 10
Japan 3 6
Australia 1 4
Canada 1 4
Ireland 1 4
Singapore 1 4
Belgium 1 2
Chile 1 2
France 1 2
Liberia 1 2
Netherlands 1 2
Spain 1 2
Switzerland 1 2
Type of publication Journal article 31 62
Conference or congress proceedings 6 12
Book or book chapter 3 6
Thesis 10 20
Objective Therapeutic 42 84
Prevention 8 16
RPG forma TRPG 22 44
LARP 3 6
CRPG 25 50
MORPG or MMORPG 5 10
Hybrid or other 2 4
Game type Commercial game 23 46
Serious game 22 44
Not specified 5 10
Technique or therapeutic linea Psychodynamic therapy 7 14
Cognitive and/or behavioral therapy 26 52
Drama therapy 3 6
Narrative therapy 2 4
Analytical/Jungian psychology 2 4
Play therapy 3 6
Expressive or recreational therapy 3 6
Interpersonal therapy 1 2
Not specified 6 12
Mode of therapy Individual therapy 28 56
Group therapy 16 32
Not specified 6 12
Population Age rangea Children (3-9 years) 9 18
Adolescents (10-24 years) 35 70
Adults (>25 years) 7 14
Not applicable 8 16
Gender Male 14 28
Female 4 8
Both 18 36
Not specified 6 12
Not applicable 8 16

a
Some studies presented more than one category in relation to characteristics.
CRPG: computer role-playing game; LARP: live-action role-playing game; MORPG: multiplayer online role-
playing game; MMORPG: massively multiplayer online role-playing game; RPG: role-playing game; TRPG:
tabletop role-playing game.
Arenas et al. 9

Results
Fifty sources of evidence were included (Figure 1). In the pilot test of titles and abstracts
screening, a kappa index of 0.95 was obtained, and at the end of this stage, reviewers
obtained a kappa index of 0.84. In full-text article eligibility evaluating, the kappa index
was 0.79, with disagreement in ten studies. After discussions, reviewers (DA and AV)
agreed on the inclusion of seven studies, and three of them were decided by the third
reviewer (one included). Table 2 presents the general characteristics of the included
sources of evidence. MMAT was used to the critical appraisal of the empirical studies
included (for complete scores, refer to Supplemental Material 3).

Protocols, narrative reviews, and opinion pieces

The three RCT protocols aim to evaluate the use of CRPGs: to investigate the use of the
Japanese culture-adapted version of a CRPG (SPARX) to improve depressive
symptoms in young people compared to the waiting list (Yokomitsu et al., 2020); to
evaluate the effectiveness of a developed CRPG for coping skills training, self-efficacy,
and help-seeking behavior in queer adolescents who have suffered bullying or cy-
berbullying (Coulter et al., 2019); and evaluate the acceptability, feasibility, and ef-
fectiveness of a mobile CRPG (Journey to the West) developed for stress management
in Asian foreign college students (Lee et al., 2014).
The three narrative reviews sought to present the historical context and structure of
commercial TRPGs (Brown, 2018; Mendoza, 2020; Tamayo, 2018) and LARPs
(Mendoza, 2020). They discussed their possible use as therapeutic tools and compared
their structures with some therapies such as psychodrama, a type of group psycho-
therapy that has as a core the exploration of the human psyche and its emotional bonds
through improvised dramatic performance (Brown, 2018; Mendoza, 2020), and nar-
rative therapy (Tamayo, 2018).
Of the five opinion pieces, Ascherman (Ascherman, 1993) highlights the potential
negative effects of the use of unstructured TRPGs in hospitalized adolescents. Hawkes-
Robinson (Hawkes-Robinson, 2008, 2016) and Franco (Franco, 2016) commented on
the benefits of using different forms of RPG for demands in recreational (Hawkes-
Robinson, 2016) and narrative therapies (Franco, 2016). Finally, Scudder (Scudder,
2018) reflected on the potential benefits of D&D for anxiety disorders while describing
the creation of a gaming campaign (a continuing storyline or set of adventures, typically
involving the same characters).

Qualitative and mixed-methods studies

Three qualitative studies were analyzed. McConnaughey (McConnaughey, 2015)
evaluated two commercial TRPGs (Apocalypse World (Baker and Baker, 2010) and
Monsterhearts (Alder, 2012)). The study also examined the possibility of developing
new therapies through game design using grounded theory and content analysis. It
10 Simulation & Gaming 0(0)

concluded that RPG sessions share structural characteristics with group therapies and
those characters can be used to facilitate the therapeutic approach. Munro (Munro,
2017) explored the intersection between MMORPGs and psychodynamic psycho-
therapy through a hermeneutic review, highlighting imagination as a mean for
fluidity and transcendence between the virtual and non-virtual world and games as a
space that allows the authentic expression of parts of the personality even while
remaining within a collective. Finally, Hughes (Hughes, 1988) reported a case that
used a commercial TRPG (Call of Cthulhu (Petersen, 1981)) to help reframe the
illness of a 27-year-old depressed woman and promote greater self-efficacy through
a psychodrama approach. In parallel, the author also interviewed five players about
the perceived benefits of RPG, emerging themes of TRPG as a promoter of escapism,
self-efficacy, social skills and as an educational tool.
Four studies used mixed methods. Two studies used semi-structured interviews and
instruments to assess the acceptability and viability of RPGs developed as comple-
mentary psychotherapeutic tools, one (Carrasco, 2016) based on cognitive-behavioral
therapy (CBT) and interpersonal therapy for depression in girls between 12 and 18
years old (CRPG Maya) and the other (Araujo et al., 2011) based on CBT for treatment
and prevention of substance use by adolescents (TRPG Desafios). Another study
(Olivet et al., 2019) used a quasi-experimental design with qualitative semi-structured
interviews to evaluate a CRPG (OnTrack) developed for people who experienced the
first-episode psychosis, with 20 clinically stable youths who showed significant im-
provement in attitudes towards treatment and recovery after a game session. A Japanese
publication (Kat o, 2019) reported findings of two concurrent studies. The first included
four adolescents with autism spectrum disorder (ASD) who participated in sixteen
TRPG group sessions, and results showed better social skills in the last sessions
compared to the first sessions. The second study evaluated 51 adolescents with ASD
before and after intervention with five TRPG group sessions, showing a statistically
significant increase in quality of life after the intervention.

Descriptive studies
Three experience reports (Bispo and Pimentel, 2019; Descamps and d’Alcantara, 2016;
Favelle, 1995) focused on the use of commercial RPGs in workshops with adolescents
under the supervision of a therapist as a way to facilitate the therapeutic process and
develop skills.
Five case reports evaluated the use of gaming experiences in psychodynamic
psychotherapy. In two cases with adolescents, commercial MMORPGs were used to
improve socialization and a sense of belonging (Limberger and Silva, 2013) and to
facilitate transference (Malberg, 2011) through avatars (digital cyberbodies or graphic
figures of varied complexity that simulates life in the game world and represents the
player in cyberspace). In a case of a 7-year-old boy with anxious symptoms after his
parents’ divorce (Allen, 1984), a commercial CRPG (Ultima (Garriott, 1981)) was
used to improve self-efficacy and reduce the stigma of undergoing therapy. In the
Table 3. Characteristics of quasi-experimental studies.
Intervention and
Arenas et al.

Reference Objective Population RPG form Primary outcomes Main results

Lucassen Describe the development of 21 non-heterosexual Complete at least 4 of the Depressive symptoms 90.5% completed at least 4/7
et al., 2015 the game for queer youth adolescents between 13 7 modules of the (CDRS-R); Feasibility modules and rated the
(New with depressive symptoms and 19 years old with developed CBT-based (complete 4 of the 7 program favorably. Depressive
Zealand) and its acceptability, depressive symptoms CRPG (Rainbow modules); Acceptability symptoms decreased post-
viability, and effectiveness. (CDRS-R ≥ 30). SPARX). (self-report). intervention (p < 0.0001, pre-
post effect size of 1.01),
maintained at 3-month follow-
up.
Almeida et al., Describe the creation of an 38 children between 3 and Use developed CRPG Emotion recognition There was no significant
2019 RPG to help autistic 13 years old, 10 with a (Altriras), once a week, (QuizEmotion software) difference in the recognition of
(Brazil) children recognize facial diagnosis of ASD and 28 for 4 weeks (60 minutes before and after the emotions in the pre and post-
expressions and neurotypic. per session). intervention; Acceptability test of children with ASD.
emoticons. (System Usability Scale). Good results of acceptability.
Ong et al., Report the development and 72 children between 6 and Use of CBT and problem- Usability/gameplay (Short There was a good acceptance of
2019 evaluation of a set of 6 12 years old, 35 with a solving therapy based Feedback Questionnaire); the game by the participants
(Singapore) applications designed to diagnosis of disruptive CRPG (RagnaTales) Game impacts on and a significant reduction of
help children and behavior disorder and developed. aggressiveness (Reactive- reactive aggressions in three of
adolescentes to control 37 with typical Proactive Aggression the applications: Rage Raver (p
anger. development. Questionnaire) = .001), Abaddon (p = .008),
and RegnaTools (p = .03).
Segal, 2017 Testing for prevention 35 college students aged Play the developed CRPG Experience and knowledge In a descriptive analysis, 96% of
(United purposes if a developed 18-25. (The Black Dog) based about depression the participants reported
States) role-playing game makes on psychoeducation for (questionnaire developed having learned, at least, a little
college students aware of depression. for the study). from the game. However, the
depression. player’s involvement and the
amount of learning can be
improved.

(continued)
11
 12

ot-

Table 3. (continued)
Intervention and
Reference Objective Population RPG form Primary outcomes Main results

Duncan et al., Evaluate an RPG prototype to 25 adolescents between 11 Play developed CRPG Acceptability of the game and Good acceptance and improved
2018 the development of and 14 years old who (smokeSCREEN) for an knowledge about cigarettes knowledge about cigarette
(United knowledge and behavioral had never smoked hour, twice a week for and marijuana in a 12-week (Wilks’ Lambda = .62, F (2, 23)
States) skills associated with the marijuana or cigarettes two weeks. follow-up (adapted = 7.21, p = .004) and
prevention of cigarette and instruments). marijuana use (Wilks’ Lambda
marijuana use. = .67, F (2, 23) = 5.75, p =
.009).
Helbig, 2019 Investigate the effects of RPG 4 children between 9 and Group social skills training Percentage of skills acquisition Improvement in the acquisition
(United on the acquisition of social 10 years old diagnosed through commercial and generalization of skills of social skills in all
States) skills in children with ASD. with ASD and TRPG twice a week, for (target social skills task participants. Mixed results
moderately high to very one hour. analysis table). regarding the generalization of
high scores on ASRS. skills.
Bagès et al., Investigate the effectiveness 86 French students Empathy training program Levels of empathy (The Significant increase in the level of
2020 of RPG as an intervention attending sixth grade. involving three 60- Empathy Scale), bullying empathy and a significant
(France) program to prevent minute sessions of LARP (Illinois Bully Scale) and decrease in bullying and
bullying. vs control group. aggressive behavior aggressive behavior in the RPG
(Aggression Scale). group in the post-test.

ASD: autism spectrum disorder; ASRS: Autism Spectrum Rating Scales; CBT: cognitive behavioral therapy; CDRS-R: Children’s Depression Rating Scale–Revised;
CRPG: computer role-playing game; LARP: live-action role-playing game; RPG: role-playing game; TRPG: tabletop role-playing game.
Simulation & Gaming 0(0)
Arenas et al. 13

her two cases (Blackmon, 1994; Coimbra, 2004), with adolescents who were already
playing D&D, content from TRPG was useful to explore fantasies and the internal
world of patients, strengthen the therapeutic bond and assist in the elaboration of
conflicts, maintaining the structure of the therapy and the game through the contract
and the rules.
Eight case series were evaluated. Four studies used adapted D&D (Enfield, 2007;
Rosselet and Stauffer, 2013; Zayas and Lewis, 1986) or developed TRPG (Shanun,
2013) for group therapy with children and adolescents with the therapist as the game
master, evaluating individual outcomes, such as social skills development, emotional
self-regulation, problem-solving, self-efficacy and motivation for treatment. Santos
(Santos, 2018) presented six cases with patients between 6 and 21 years old in which
commercial TRPGs were used in psychotherapy to deal with grief, generating the
hypothesis that patients can project content on characters and narratives, configuring
the game as a ritual. Kokish (Kokish, 1995) describes five cases of male adolescent
victims of abuse or neglect in which commercial CRPGs were used in psychotherapy,
resulting in clinical improvement and therapeutic relationship facilitation. Two studies
described cases in which CRPGs developed with elements of CBT (Clarke and
Schoech, 1995) and problem-solving therapy (Coyle et al., 2005) were used in a
complementary way to the individual therapy of male adolescents, showing good
acceptance by patients and therapists.

Quasi-experimental, cohort and experimental studies

Seven quasi-experimental studies with pre-test and post-test methodology (Table 3),
one cohort study, and eight experimental studies (Table 4) were analyzed.

RPG applications in mental health

Most studies investigated RPG as a therapeutic tool (84%) in a complementary way
to a psychotherapeutic approach or developed based on psychotherapy techniques.
Prevention studies (16%) focused on depressive symptoms (n=3), substance use
(n=2), coping strategies (n=2) and bullying (n=1). The most used therapies were
those that follow cognitive and/or behavioral lines (52%), using skills training
techniques, problem-solving, psychoeducation, exposure, and cognitive re-
structuring, followed by psychodynamic therapies (14%) that focus on the un-
conscious and transference phenomena. 90.9% of empirical studies reported
objective or subjective improvement concerning the outcomes assessed after the use
of RPG-based interventions.
The characteristics explored in the samples varied between psychopathologies and
socio-cultural or behavioral conditions: depression (n=10); ASD (n=4); unspecified or
comorbid psychiatric disorders (n=4); disruptive, impulse control, and conduct dis-
orders (n=4); attention-deficit/hyperactivity disorder (n=2), substance use disorders
(n=2), anxiety disorders (n=3), shyness (n=2), victims of abuse or neglect (n=2), queer
14 Simulation & Gaming 0(0)

(n=2), foreign (n=2), grieving (n=1), trauma (n=1), first-episode psychosis (n=1) and
schizoid personality (n=1).
The most cited commercial RPG and serious game were D&D (n=8) and SPARX
(n=8), respectively. CRPGs are single-player modalities and were used in individual
therapies, 80% as serious games and 80% based on cognitive or behavioral techniques.
On the other hand, TRPGs and LARPs are collaborative game modalities and more
related to group therapies (68%). Also, those collaborative game modalities were more
used in their commercial versions (76%), often adapted (26,31%). MMORPGs, despite
their characteristic of simultaneous players, were used in the included studies as
complementary to individual therapy and in their commercial form.

Discussion
To our knowledge, this is the first review using systematic methods that focuses on the
use of RPGs in psychotherapy and mental health. Fifty primary or secondary studies
were included, with only 62% published in peer-reviewed journals, evidencing a large
amount of grey literature on the subject (n=19). Although the first RPGs gained strength
in the 70s and 80s, most studies were published from 2011 (78%). It may be associated
with the greater interest of several disciplines in game studies, which began to establish
itself as a field of study in the previous decade (Deterding and Zagal, 2018).
RPGs or their elements were used or adapted as complementary tools to psycho-
therapeutic techniques in all the studies included, especially in cognitive and/or be-
havioral approaches (52%) and focusing on the adolescent population (70%). Parallel
to this, the most used forms of RPG were CRPGs (50%), highlighting digital media as
possible means of intervention, which corroborates the growing interest in investi-
gations about the effectiveness of computer-mediated CBT (Andrews et al., 2018).
This interest intensifies itself in the current context of the COVID-19 pandemic since
telehealth services and the use of digital resources in therapies have been more
encouraged (Smith et al., 2020). In this line, the elements of RPG and videogames
can be a path that allows greater engagement and immersion in interventions
(Bowman, 2018), in addition to promoting well-being and social connectedness
(Riva et al., 2020).
Among the evaluated CRPGs, SPARX, a serious game with RPG elements -
customization and interpretation of characters in a fictional world of fantasy and with
progression when completing the quests - and structured as CBT sessions for the
treatment of depressive symptoms in adolescents accumulates more evidence, with five
RCTs (Fleming et al., 2012; Kuosmanen et al., 2017; Merry et al., 2012; Perry et al.,
2017; Poppelaars et al., 2016) and favorable acceptability. The intervention seems
effective for adolescents with mild to moderate depression and not inferior to usual
treatment with face-to-face therapy (Merry et al., 2012).
Nonetheless, there was also a large number of studies employing traditional TRPGs
(44%) such as D&D (Gygax and Arneson, 1974), Monsterhearts (Alder, 2012), World
of Darkness (Rein-Hagen, 1991), and Call of Cthulhu (Petersen, 1981) which, like
Table 4. Characteristics of experimental and cohort studies.
Intervention and
Arenas et al.

Reference Study design Population RPG form Primary outcomes Main results

Perry et al., 2017 Cluster RCT. 540 students with an average
(Australia) age of 16 years before a
stressor (high school final
exams).
Poppelaars et al., RCT. 208 girls between 11 and 16
2016 years old attending the first
(Netherlands) or second year of high
school.
Merry et al., Multicenter RCT 187 adolescents with mild or Intervention group (n = 94): 7 SPARX Depressive symptoms
2012 (New of non- moderate depression, aged
Zealand) inferiority with 12 to 19 years, with no high
blinding risk of self-harm, and who
researchers. sought help in primary care
or counseling service,
Intervention group (n = 242): SPARX-R Depressive symptoms (Major Compared to controls, SPARX-R
(CRPG), one module per week for 7 Depression Inventory). participants showed a significant
weeks. Control group (n = 298): reduction in depressive
lifeSTYLE, online intervention of 7 symptoms in the post-
modules created as a control. intervention period (d = 0.29)
and after 6 months of follow-up
(d = 0.21), but not after 18
months (d = 0.33).
OVK Group (prevention program) (n = Depressive symptoms The intention to treat results
50); SPARX group (CRPG) (n = 51); (RADS). showed that depressive
group OVK and SPARX combined (n symptoms decreased equally in
= 56); and control group (n = 51). all groups (F (12, 1853.03) =
14.62, p <0.001).
SPARX was not inferior to the usual
modules (CRPG) in a period of 4 to 7 (CDRS-R). treatment. In the post-
weeks, Control group (n = 93): usual intervention, there was an
treatment (face to face therapy). average reduction of 10.32 in the
SPARX and 7.59 in the usual
treatment in the scale scores
(2.73, 95% CI -0.31-5.77; p =
0.079). The remission rate was
significantly higher in the SPARX
arm (17.3%, 95% CI 1.6-31.8%; p
= 0.03) and the response rate did
not differ. Intention-to-treat
analyzes confirmed these findings
and were maintained at three-
month follow-up.

(continued)
15
 16

Table 4. (continued)
Intervention and
Reference Study design Population RPG form Primary outcomes Main results

Ong et al., 2013 Pilot RCT study. 21 children between 9 and 12
(Singapore) years old, diagnosed with
anxiety disorder.
Fleming et al., RCT. 32 male adolescents between Intervention group (n = 20): SPARX
2012 (New 13 and 16 years old with high (CRPG) for 5 weeks. Control group (n
Zealand) scores on the CDRS-R,
excluding those at risk of
suicide or with severe
depression.
CBT-based CRPG (CASTLE-AC). CAT
Group: 8-session computer-assisted
therapist; TAC Group: 3-session
therapist-assisted computer; Control CGI).
group: usual treatment (8 CBT
sessions).
= 12): waiting list.
Anxious symptoms (Children Improvement in parental reporting
Anxiety Scale, Asian on the Spence Children Anxiety
Children Anxiety Scale and Scale (p <0.05) in the CAT group
(n = 7) at 3-month follow-up;
improvement in Asian Children
Anxiety Scale (P <0.05) and CGI
(p <0.01) in the TAC group (n =
6). Improvement only in CGI (p
<0.05) in the control group (n =
8). ANOVA showed no
difference between groups.
Adherence to treatment 81% of participants completed at
(sample retention rates); least 4 SPARX modules and 69%
depressive symptoms completed all levels. Significant
(CDRS-R and RADS). differences were found between
the SPARX group and the post-
intervention control group on
CDRS-R (-14.7 vs. -1.1, p
<0.001), remission (78% vs. 36%,
p = 0.047) and on RADS (-4.6 vs.
+3.2 p = 0.05). In intention to
treat analyze the results of the
CDRS-R and remission rates
remained significant. The gains
were maintained over 10 weeks
of follow-up.

(continued)
Simulation & Gaming 0(0)
Table 4. (continued)
Intervention and
Reference Study design Population RPG form Primary outcomes Main results
Arenas et al.

Kuosmanen Pilot RCT study. 146 youths between 15 and 20 Intervention group: SPARX-R (CRPG), Adherence to treatment Participants completed an average
et al., 2017 years old in an alternative for 7 weeks. Control group: no (sample retention rates); of 5.3 SPARX-R modules. A
(Ireland) education program. intervention. depressive symptoms significant improvement in
(Short Moods and Feelings emotional regulation strategies
Questionnaire). was detected in the SPARX-R
group compared to the control
group ( 2.97, 95% CI 5.48 to
0.46, p = 0.03). There was no
significant difference in
depressive symptoms between
groups.
Tajima et al., RCT. 64 college students with high Training group (n = 20): MMORPG Improvement in shyness There was a significant difference
2014 (Japan) shyness scores on the Trait within the program developed to (three validated shyness between the control and training
Shyness Scale. improve shyness (4.5 hours per week, scales and a self-esteem groups on two shyness scales
for 5 weeks); MMORPG group (n = scale) immediately and one right after training. Self-esteem
20): MMORPG played freely; Control month after the scores were higher in the training
group (n = 24): without intervention. intervention. group than in the control group.
There was no difference between
groups after one month.
Scattone and RCT. 10 inpatient (>30 days) male Intervention group (n = 5): coping skills Participants’ self-confidence in Compared with the control group,
Tucci, 2018 participants over 18 years training with weekly use for 1.5 hours their ability to cope with the training provided an increase
(Brazil) old, diagnosed with chemical of an adapted TRPG System (World of drug use in at-risk situations in the participants’ self-
dependence and high ASSIST Darkness(Rein-Hagen, 1991)) for four (ASSIST and Brief confidence in coping with
scores, and without other weeks in a group format. Control Situational Confidence different risk situations that
comorbidities. group (n = 5): without intervention. Questionnaire). trigger the use of drugs (personal,
family, and social conflicts).
There was also an increase in self-
confidence to refuse drug use in
moments that used it
uncontrollably.

(continued)
17
 18

Table 4. (continued)
Intervention and
Reference Study design Population RPG form Primary outcomes Main results

Fleming et al., Stepwise cohort 40 male adolescents between Intervention group (n = 19): usual Depressive symptoms Only two participants completed
2019 (New study. 14 and 17 years old treatment (offenders’ program) for 10 (RADS) and change in two or more modules of the 7-
Zealand) participating in a offenders’ to 20 weeks plus SPARX-R (CRPG). antisocial cognitions (How I module program, so it was not
program. Control group (n = 21): offenders’ Think questionnaire). possible to assess the impact as
program for 10 to 20 weeks. planned. The four participants
who provided feedback were
indifferent or rated SPARX-R
negatively.

ANOVA, analysis of variance; ASSIST, Alcohol, Smoking and Substance Involvement Screening Test; CBT, cognitive behavioral therapy; CDRS-R, Children’s
Depression Rating Scale-Revised; CGI, Clinical Global Impressions scale; CRPG, computer role-playing game; MMORPG, massively multiplayer online role-playing
game; RADS, Reynolds Adolescent Depression Scale; RCT, randomized controlled trial; TRPG, tabletop role-playing game.
Simulation & Gaming 0(0)
Arenas et al. 19

LARPs (6%), have a structure similar to some group psychotherapy techniques

(McConnaughey, 2015) and can enable socialization, problem-solving and social
communication due its cooperativeness and creativity (Bowman, 2010; Fein, 2015).
Thus, some studies highlight its use for skills training (Araujo et al., 2011; Enfield,
2007; Helbig, 2019; Kat o, 2019; Rosselet and Stauffer, 2013; Scattone and Tucci,
2018; Zayas and Lewis, 1986) and as a way to facilitate the therapeutic bond and
explore internal issues of patients through the characters and the narrative present in the
games (Bispo and Pimentel, 2019; Blackmon, 1994; Coimbra, 2004; Descamps and
d’Alcantara, 2016). MMORPGs appeared in 10% of the included studies, using elements
such as the exploration of the player’s relationship with his internal world and the avatar
(Malberg, 2011; Munro, 2017) and the socialization present in the game (Limberger and
Silva, 2013; Tajima et al., 2014) as a therapeutic tool. Along these lines, some elements
related to the attractive and even addictive properties of MMORPGs, such as the rein-
forcement scheme with rewards, social interactions, and the exploration of identity and
relationships through avatars, can be useful in therapeutic settings or a well-being pro-
motion (Bessière et al., 2007; Scott and Porter-Armstrong, 2013; Thorens et al., 2016).
We identified gaps in the literature. Only 16% of the included studies had an ex-
perimental design, and not all had an adequate sample size. Also, despite 90.9% (n=30) of
the included empirical studies reporting favorable outcomes after the intervention, only
one study (Merry et al., 2012) met all the quality criteria of the MMAT, showing
methodological limitations and risks of bias in most studies in this scoping review.
Another important point is the non-standardization of the definitions, forms, and
characteristics of RPGs in the literature. Some included studies provided a superficial
description of the games used or did not focus on the influence of the RPG’s inherent
elements in the outcomes. Besides, the scarcity of well-designed studies and the
heterogeneity of interventions prevented the conduction of systematic reviews.

Limitations
Considering the importance of an interdisciplinary view on games and academic
advances in establishing the field of game studies, this review has a limitation as it
does not include a researcher with more experience in game studies or game design.
Another limitation we faced was the non-inclusion of studies published in other
languages, resulting in the exclusion of dozens of studies in the title and abstract
screening. Additionally, due to non-indexing issues in the databases used, the
heterogeneity of terms used in studies on the subject, and the existence of more
recent works that were not cited in articles published until the end of 2020, some
references ended up not being identified by our protocol (see Connell and Dunlap,
2020; Connell et al., 2020). Therefore, we did not include these works in the present
review, especially since the posterior inclusion of such references could com-
promise the reproducibility of the review. Finally, several studies did not specify nor
describe in detail the elements and characteristics of the games evaluated, making it
20 Simulation & Gaming 0(0)

difficult to identify the game as an RPG according to the broad definition adopted
for this review.

Conclusion
Based on this scoping review, we identified that RPGs have been used in mental health
as therapeutic tools complementary to psychotherapies, especially in CBT, and fo-
cusing on depression. The main forms of RPG used were CRPGs and TRPGs. The most
investigated population was male adolescents. Most studies showed favorable out-
comes after the application of RPG as a therapeutic or preventive tool. However, only
16% of the studies were experimental, with great heterogeneity in the definitions of
RPG, evaluated outcomes and interventions. Therefore, more well-designed empirical
studies are needed to support the use of RPG or RPG-based interventions in clinical
populations. RPG is a complex and heterogeneous phenomenon, and therefore it is vital
that future studies specify the elements within RPG that are being investigated as
intervention strategies, and what are the differences between serious games and
commercial RPGs in mental health outcomes. Moreover, the collaboration between
health sciences researchers, game studies researchers, and people with experience as
players should be encouraged to further knowledge in the area.

Acknowledgments
Bárbara Piffer and Maria Silvia Robaina de Souza Lessa provided consultancy for the elaboration
of the search strategy. Daniel Tornaim Spritzer and Francisco Grendene Botti collaborated with
notes and evaluation of the initial version of this article. We also thank all the RPG players who
inspired this review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this
article: This research received non-specific grant from any funding agency in the public,
commercial or not-for-profit sectors.

ORCID iD
Daniel Luccas Arenas  https://orcid.org/0000-0003-2860-9101

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